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

Indications, Associated Procedures, and Results of Ankle Plafond-Plasty for Varus Ankle Osteoarthritis: A Systematic Review and Meta-Analysis

BACKGROUNDS

Plafond-plasty is a joint-preserving procedure to treat varus ankle osteoarthritis (OA) with asymmetrical joint involvement. The aim of this systematic review and meta-analysis was to evaluate indications, different surgical techniques, associated procedures, and results of plafond-plasty in varus ankle OA and to analyze the level of evidence (LOE) and quality of evidence (QOE) of the included studies.

METHODS

A systematic review of the literature was performed using MEDLINE, Embase, and Cochrane.

RESULTS

Five studies evaluating 99 ankles were included. A non-rigid varus ankle deformity and an ankle OA Takakura stage 3b or less were the most recommended pre-operative indications. Meta-analysis showed a significant post-operative improvement in clinical and radiological parameters. Many associated surgical procedures have been reported, the most frequent being medial additional supramalleolar osteotomy and lateral ankle ligament reconstruction. The level of evidence and methodological quality assessment of the included studies showed an overall low quality.

CONCLUSION

Plafond-plasty seems to be a promising surgical option when managing varus ankle OA with asymmetrical joint involvement, extending the indications for joint sparing surgery. Additional associated procedures should be carefully evaluated case-by-case.

LEVELS OF EVIDENCE

IV.

Does a rupture of the lateral ankle ligament need to be repaired in supination-adduction type II (OTA/AO 44A2) fractures?

PURPOSE

To evaluate the outcomes of patients with supination-adduction (SAD) type II (OTA/AO 44A2) fractures who had a lateral ankle ligament rupture repaired compared with patients who did not have a lateral ankle ligament repaired using patients who underwent fibula fracture fixation as a control group.

METHODS

A retrospective analysis of all 104 patients diagnosed with SAD type II fractures from January 2011 to December 2020 and managed operatively was performed. The patients were divided into three groups: 32 patients with ruptures of the lateral ligaments that were not repaired (group A), 34 patients with ruptures of the lateral ligaments that were repaired (group B), and 38 patients with fibula fracture fixation acting as the control group (group C). The objective outcomes including radiographic findings, the ankle range of motion, the manual ankle stress tests, and complications were gained from the record of the last time in outpatient clinics. The functional outcomes including the identification of functional ankle instability (IdFAI) scores were collected postoperatively at 12-month intervals to assess clinical outcomes. The Manchester Oxford Foot Questionnaire (MOXFQ) and Karlsson scoring scale were also recorded at the last follow-up.

RESULTS

The mean follow-up of the objective and subjective functional outcomes was 23.4 (range, 13-42) and 76.9 (range, 25-134) months, respectively. There was no significant difference in the radiographic findings, the ankle range of motion and complications between the three groups. All ankles were found to be stable using the manual ankle stress test in both group A and group B. The IdFAI scores showed a significant difference between group A and group B (1.12 ± 1.3 vs 0.35 ± 0.69; p < 0.001) in the first year of follow-up and no significant difference after the first year. No differences were noted in MOXFQ scores or Karlsson scores among the groups.

CONCLUSION

Directly repairing the lateral ligament could minimize the proportion of the first year of postoperative functional ankle instability, although the final stability of the ankle and clinical outcomes were not significantly different in SAD type II fractures.

LEVEL OF EVIDENCE

Level III, retrospective comparative case series.

Joint Preservation for Posttraumatic Ankle Arthritis After Tibial Plafond Fracture

Management of posttraumatic ankle arthritis due to tibial plafond fracture is technically demanding. The distal tibial plafond-plasty could be an alternative to preserve the ankle joint for young patients with limited ankle arthritis. The surgical principles are to realign the mechanical axis, reconstruct the articular surface of the distal tibial plafond, and achieve a congruent and stable ankle joint. In addition to the anteroposterior view of the ankle joint, the lateral view was also paramount for surgeons to fully evaluate the reduction quality. The revision procedures are as follows: osteotomy for exposure, articular surface reconstruction, bone grafting, and osteotomy fixation.

Anterior distal tibial plafond-plasty for the treatment of posttraumatic ankle osteoarthritis with anterior translation of the talus

Posttraumatic ankle osteoarthritis (OA) represents a significant challenge to orthopedic surgeons, especially in cases of anterior talar translation and concomitant impaction of the anterior distal tibial plafond. The aim of this study was to evaluate the clinical outcomes of an intra-articular osteotomy for the management of these patients. A total of 21 patients meeting our criteria were retrospectively reviewed. Sixteen patients sustained initial pilon fractures, while five patients had Weber type C ankle fractures. Anterior distal tibial plafond-plasty was performed to address the impaction and anterior translation of the talus. The American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score and visual analog scale (VAS) score were utilized as clinical outcomes. The lateral talar station (LTS), tibial lateral surface (TLS) angle, tibial anterior surface angle and talocrural angle were evaluated pre- and postoperatively. The modified Kellgren-Lawrence score was used for the evaluation of sagittal ankle OA. The average age at surgery was 35 years, and the average follow-up duration was 34 months. The AOFAS hindfoot score increased from 26 to 71 (p < 0.01), and the VAS score improved from 7 to 2 (p < 0.01). The LTS improved from 9.0 to 2.3 mm (p < 0.01), and the TLS angle improved from 72° to 81° (p < 0.01). Of the 21 patients, 18 showed improvement in or no worsening of ankle OA on the sagittal plane, while 3 developed advanced ankle OA. A congruent ankle joint on the sagittal plane could be achieved by anterior distal tibial plafond-plasty. This is a valuable treatment option for the salvage of posttraumatic ankle OA with anterior translation of the talus.

Reconstruction of Severe Ankle and Pilon Fracture Malunions

Malunion of ankle and pilon fractures has significant detrimental effect on function and development of post-trauma osteoarthritis. Unfortunately, the incidence of malunion has been reported to be increasing. It is important to assess the ankle for congruency, because this determines the level where correction will occur. A plethora of techniques are available, with low-level evidence supporting each, and therefore it is important that the treating surgeon is fully prepared and comfortable in the techniques they are to use. Supplementary procedures are common and should be expected. This article provides a review of current methods of treatment and their outcomes.

Effectiveness of distal tibial osteotomy with distraction arthroplasty in varus ankle osteoarthritis

Background

In highly active older individuals, end-stage ankle osteoarthritis has traditionally been treated using tibiotalar arthrodesis, which provides considerable pain relief. However, there is a loss of ankle joint movement and a risk of future arthrosis in the adjacent joints. Distraction arthroplasty is a simple method that allows joint cartilage repair; however, the results are currently mixed, with some reports showing improved pain scores and others showing no improvement. Distal tibial osteotomy (DTO) without fibular osteotomy is a type of joint preservation surgery that has garnered attention in recent years. However, to our knowledge, there are no reports on DTO with joint distraction using a circular external fixator. Therefore, the purpose of this study was to examine the effect of DTO with joint distraction using a circular external fixator for treating ankle osteoarthritis.

Methods

A total of 21 patients with medial ankle arthritis were examined. Arthroscopic synovectomy and a microfracture procedure were performed, followed by angled osteotomy and correction of the distal tibia; the ankle joint was then stabilized after its condition improved. An external fixator was used in all patients, and joint distraction of approximately 5.8 mm was performed. All patients were allowed full weight-bearing walking immediately after surgery.

Results

The anteroposterior and lateral mortise angle during weight-bearing, talar tilt angle, and anterior translation of the talus on ankle stress radiography were improved significantly (P < 0.05). Signal changes on magnetic resonance imaging also improved in all patients. Visual analog scale and American Orthopedic Foot & Ankle Society scores improved significantly (P < 0.05), and no severe complications were observed.

Conclusion

DTO with joint distraction may be useful as a joint-preserving surgery for medial ankle osteoarthritis in older patients with high levels of physical activity.

Level of evidence

Level IV, retrospective case series.