Extraarticular Supramalleolar Osteotomy in Asymmetric Varus Ankle Osteoarthritis

Pressure change at ankle joint in supramalleolar osteotomy with or without fibular osteotomy according to different types of varus ankle

The need for additional fibular osteotomy (FO) when performing supramalleolar osteotomy (SMO) in the varus ankle arthritis (VAA) is controversial. Some cadaveric studies have been performed to prove this; however, it is difficult to implement deformities including talar tilting and translation in cadavers. In this study, we created a model of VAA with the tilting and translation using three-dimensional (3-D) finite element (FE) analysis and analyzed the results of SMO with or without FO depending on the types of VAA. The validated normal foot and ankle 3-D FE model was constructed including the ankle cartilages of the talar dome and tibia plafond. The VAA models were determined and reconstructed by following the classification of VAA, VAA with medial translation for stage 3a, VAA with varus tilting (7.5°) for stage 3b. The postoperative SMO models (SMO with and without FO) were reconstructed by corresponding to each VAA models. The FE analysis conditions were commonly applied. The boundary condition of ankle joint was defined as "sliding condition" and applied 0.002 friction coefficient to realize lubricative property. Loading condition was assumed as a two-leg standing position and half of the subject body weight (325 N) was loaded on center of ground to vertical direction. Contact pressure changes were predicted at the medial ankle cartilage. As a result, in VAA with medial translation, isolated SMO may provide sufficient pressure reduction at the medial ankle joint. However, in VAA with varus tilting, SMO combined with FO could appropriately relieve concentrated pressure at the medial ankle joint.

Analysis of radiologic parameters and clinical outcomes in supramalleolar osteotomy for varus ankle osteoarthritis: A novel method for evaluating ankle alignment

BACKGROUND

Solely relying on the tibial ankle surface (TAS) angle for determining the mechanical ankle axis might be insufficient. We introduce a novel method to determine the distance from the center of the talus to the tibial axis (TTD). This study aimed to investigate the association between clinical outcomes and radiological changes before and after supramalleolar osteotomy (SMO), including TAS angle, talar tilt (TT) angle, tibiotalar surface (TTS) angle and TTD.

METHODS

Seventy patients who received SMO were enrolled. Radiological changes were measured using weight-bearing anteroposterior imaging. The percentage of talar center displacement (TTDP) was calculated as the difference between postoperative and preoperative TTD, divided by talar width (TW). Clinical assessments were performed using the American Orthopedic Foot and Ankle Society ankle-hindfoot (AOFAS) scale. Differences in the aforementioned indicators before and after the operation were analyzed. We defined ΔAOFAS, ΔTAS, ΔTT and ΔTTS as the difference between postoperative and preoperative values.

RESULTS

ΔTTS correlated with ΔAOFAS (r = 0.40, p = 0.008), as did TTDP (r = 0.32, p = 0.035). No correlation was observed between ΔAOFAS and ΔTAS. In the comparison between groups, patients with a TTDP greater than 26.19 exhibited a significantly greater ΔAOFAS. The high intraclass correlation coefficient indicated good reliability of the novel method.

CONCLUSION

Solely relying on the TAS angle for tibial correction was insufficient. We found TTD as a novel method to evaluate mechanical ankle joint axis. TTDP and ΔTTS both positively correlated with ΔAOFAS, indicating the usefulness of these radiologic parameters.

Hindfoot motion according to subtalar compensation and ankle osteoarthritis stage analyzed by a multi-segment foot model

BACKGROUND

The biomechanics of the hindfoot in ankle osteoarthritis (OA) are not yet fully understood. Here, we aimed to identify hindfoot motion in a gait analysis using a multi-segment foot model (MFM) according to ankle OA stage and the presence of subtalar compensation defined by hindfoot alignment.

METHODS

We retrospectively reviewed the medical records, plain radiographs, and gait MFM data of 54 ankles admitted to our hospital for the treatment of advanced ankle OA. Spatiotemporal gait parameters and three-dimensional motions of the hindfoot segment were analyzed according to sex, age, body mass index, Takakura classification, and the presence of subtalar compensation. Twenty ankles were categorized as compensated group, and 34 ankles as decompensated group.

RESULTS

No spatiotemporal gait parameters differed significantly according to the presence of subtalar compensation or ankle OA stage. Only normalized step width differed significantly (P = 0.028). Average hindfoot motion (decompensation vs. compensation) did not differ significantly between the sagittal and transverse planes. Graphing of the coronal movement of the hindfoot revealed collapsed curves in both groups that differed significantly. Compared with Takakura stages 3a, 3b, and 4, cases of more advanced stage 3b had a smaller sagittal range of motion than those of stage 3a (P = 0.028). Coronal movement of the hindfoot in cases of Takakura stage 3a/3b/4 showed a relatively flat pattern.

CONCLUSIONS

The spatiotemporal parameters were not affected by the hindfoot alignment resulting from subtalar compensation. The sagittal range of hindfoot motion decreased in patients with advanced ankle OA. Once disrupted, the coronal movement of the subtalar joint in ankle OA did not change regardless of ankle OA stage or hindfoot compensation state.

Functional and radiographic assessments of post-traumatic asymmetrical ankle osteoarthritis treatment using supramalleolar osteotomies

PURPOSE

This study's objective is to assess the effectiveness of supramalleolar osteotomies (SMOT) in the treatment of asymmetrical ankle osteoarthritis in terms of the improvement in alignment assessed radiographically and its impact on symptoms measured by the American Orthopedic Foot and Ankle Society ankle-hindfoot score (AOFAS ankle-hindfoot score).

METHODS

Twelve patients participated in this prospective observational case series study. Standing anteroposterior, true lateral, and mortise views radiographs were taken. For preoperative planning, the lateral distal tibial angle (LDTA), talar tilt (TT), talocrural angle (TCA), and anterior distal tibial angle (ADTA) were all measured. A medial opening wedge osteotomy mainly was used to treat the varus arthritis ankle. A further oblique fibular osteotomy is frequently necessary.

RESULTS

The male-to-female ratio was 3:1, and the mean age of the patients was 26.25 ± 13.032 years. There were highly statistically significant differences between pre-and post-operative AOFAS ankle-hindfoot score (p < 0.001). Statistically significant differences concerning ankle range of motion (p = 0.002, < 0.001) of dorsiflexion and planter flexion were detected. Comparison between pre-and post-operative patients' radiology characteristics shows statistically significant differences concerning TT (p = 0.016) and LDTA (p = 0.046).

CONCLUSION

SMOT is very effective in the treatment of post-traumatic ankle osteoarthritis and postpones ankle fusion or total ankle replacements. This surgery significantly improves functional and radiological outcomes as well as the range of motion in the ankle. Meticulous preoperative planning by radiological measurements of different angles around the ankle is considered the crucial factor in success of that operation.

Radiographic Evaluation of the Association between Foot Deformities and Ankle Medial Osteoarthritis

Background

Foot deformities can cause abnormal biomechanics of the ankle joint and the development of osteoarthritis. It was hypothesized that foot deformities would be related to medial ankle osteoarthritis, and this study investigated this relationship using radiographic measurements.

Methods

Seventy-six ankles of 76 patients (32 men and 44 women; mean age, 69.0 years) with medial ankle osteoarthritis were included. Eleven radiographic measurements evaluated ankle joint orientation (tibial plafond inclination [TPI], medial distal tibial angle [MDTA], and anterior distal tibial angle [ADTA]), ankle joint incongruency (tibiotalar tilt [TT]), foot deformities (lateral talo-first metatarsal angle [Lat talo-1MT], anteroposterior talo-first metatarsal angle [AP talo-1MT], and talonavicular coverage), talar body migration (medial talar center migration [MTCM] and anterior talar center migration [ATCM]), internal rotation (IR) of the talus, and mechanical tibiofemoral angle. All were statistically analyzed using Pearson's correlation coefficients and regression analyses.

Results

Ankle joint orientation to the ground (TPI, p = 0.002), increased foot arch (Lat talo-1MT, p < 0.001), and IR of the talus (p = 0.001) were significantly associated with ankle joint incongruency (TT) in linear regression analysis. Ankle joint incongruency (TT, p = 0.003), medial talar body migration (MTCM, p = 0.042), and increased foot arch (Lat talo-1MT, p = 0.022) were significantly associated with IR of the talus in the binary logistic regression analysis. MTCM was significantly correlated with TPI (r = 0.251, p = 0.029), TT (r = 0.269, p = 0.019), MDTA (r = 0.359, p = 0.001), ATCM (r = -0.522, p < 0.001), and AP talo-1MT (r = 0.296, p = 0.015). ATCM was significantly correlated with TPI (r = -0.253, p = 0.027), ADTA (r = 0.349, p = 0.002), and Lat talo-1MT (r = -0.344, p = 0.002).

Conclusions

Ankle joint orientation, foot deformities, and talar rotation were associated with ankle joint incongruency in medial ankle osteoarthritis when evaluated radiographically. These findings need to be considered during surgical treatment for medial ankle osteoarthritis. However, the biomechanical significance of these radiographic measurements requires further investigation.

Changes in clinical outcomes and alignment of the ipsilateral knee and ankle after supramalleolar osteotomy in patients with varus osteoarthritis of the ankle: a short-term follow-up study

PURPOSE

The purpose of this study was to investigate the changes in clinical outcomes and alignment of the ipsilateral knee and ankle in patients with varus ankle osteoarthritis after supramalleolar osteotomy (SMO).

METHODS

We retrospectively reviewed 23 patients (24 ankles) with Takakura II, IIIa and IIIb ankle osteoarthritis treated with SMO between May 2017 and March 2022. The radiologic parameters of ankles contained medial distal tibial angle (TAS), tibiotalar angle (TT), tibial lateral surface (TLS), tibial plafond inclination (TPI) and talar inclination (TI). The radiologic parameters of knees contained medial proximal tibial angle (MPTA), joint line convergence angle (JLCA), the knee joint line orientation relative to ground (G-KJLO) and WBL. Hip-knee-ankle angle (HKA) was also collected. The Takakura system was used for evaluating the ankle osteoarthritis and the Kellgren-Lawrence (KL) system was used for evaluating the knee osteoarthritis. Clinical evaluation of the ankle joints contained American Orthopedic Foot and Ankle Society (AOFAS), range of motion (ROM) and visual analogue scale (VAS). Clinical evaluation of the knee joints contained Japanese Orthopaedic Association Scores (JOA), ROM, VAS.

RESULTS

The mean follow-up times were 20.3 ± 7.3 months (range 12-38). According to the radiologic evaluation, the TAS increased from preoperative 84.7° ± 2.0° to 91.2° ± 1.8° at the last follow-up (P < 0.001). The TPI and TI decreased from 4.4° ± 4.2° and 11.0° ± 5.2° to 0.1° ± 4.7° and 4.1° ± 4.8° (P < 0.001 for both). The TT angel improved from 9.5° ± 4.1° to 4.9° ± 3.3° (P < 0.001). No significant differences were found regarding MPTA, JLCA, G-KJLO, knee WBL and HKA (P > 0.05 for all). The Takakura stage improved after SMO (P < 0.001) whilst the KL stage maintains the similar lever (P > 0.05). According to the clinical evaluation, the AOFAS significantly increased from 67.5 ± 10.6 to 88.5 ± 9.3 and the VAS of the ankle decreased from 4.7 ± 1.6 to 1.2 ± 1.1, whilst there were no changes on VAS and even the JOA and knee ROM after SMO (P > 0.05 for all).

CONCLUSIONS

SMO can alleviate the symptoms of varus ankle osteoarthritis and delay the time for ankle replacement or arthrodesis by redistributing the abnormal stress of the ankle and restoring the congruence of the tibiotalar joint. In addition, it did not induce the clinical symptoms of knee without compromising lower limb alignment or knee joint line orientation in the short term.

LEVEL OF EVIDENCE

Level IV case series.

Efficacy of supramalleolar osteotomy in the treatment of traumatic ankle joint varus deformity in adolescents

BACKGROUND

Supramalleolar osteotomy (SMOT) has emerged as a valuable treatment for ankle varus deformity; however, there are fewer reports of treatment outcomes in adolescents. The purpose of this study was to investigate the radiologic and clinical outcomes of SMOT for the treatment of traumatic ankle joint varus deformity (TAVD) in adolescents.

METHODS

We reviewed 32 adolescent cases who underwent SMOT between February 2017 and February 2022 for TAVD. Radiologic assessment included tibial anterior surface angle (TAS), talar tilt angle (TT), and tibial lateral surface angle (TLS) preoperatively and at 3 months and 12 months postoperatively, and clinical assessment was performed using American Orthopaedic Foot and Ankle Society (AOFAS) scores, Visual Analogue Scale (VAS) scores, and ankle dorsiflexion-plantarflexion ROM including preoperative and 6 months postoperative and 12 months postoperative.

RESULTS

All 32 patients were followed up completely with a mean follow-up of (20.3 ± 3.2) months. From the radiologic outcomes, the mean preoperative TAS improved from 61.53 ± 3.74 to 88 ± 1.72 at 12 months postoperatively, the mean preoperative TT decreased from 2.25 ± 1.32 to 0.5 ± 0.57 at 12 months postoperatively, the mean preoperative TLS improved from 76.72 ± 0.21 to 79.34 ± 1.52 at 12 months postoperatively, the differences between the above preoperative and 12 months postoperative radiologic outcomes were statistically significant (p < 0.05), the mean preoperative AOFAS score improved from 65.5 ± 9.40 to 92.34 ± 4.00 at 12 months postoperatively, the mean preoperative VAS score decreased from 2.44 ± 1.24 to 0.78 ± 0.75 at 12 months postoperatively, and the mean preoperative range of motion (ROM) of ankle improved from 50.16 ± 7.46 to 55.78 ± 4.77 at 12 months postoperatively. The differences between the above preoperative and 12 months postoperative clinical results were statistically significant (p < 0.05).

CONCLUSION

Our study demonstrated that SMOT was effective in correcting TAVD and significantly improving ankle function in adolescents, and that it is an efficient and successful method for restoring ankle joint congruence and normal hindfoot alignment.

The Unloading Effect of Supramalleolar Versus Sliding Calcaneal Osteotomy for Treatment of Osteochondral Lesions of the Medial Talus: A Biomechanical Study

Background

In patients with osteochondral lesion, defects of the medial talus, or failed cartilage surgery, a periarticular osteotomy can unload the medial compartment.

Purpose

To compare the effects of supramalleolar osteotomy (SMOT) versus sliding calcaneal osteotomy (SCO) for pressure redistribution and unloading of the medial ankle joint in normal, varus-aligned, and valgus-aligned distal tibiae.

Study Design

Controlled laboratory study.

Methods

Included were 8 cadaveric lower legs with verified neutral ankle alignment (lateral distal tibial angle [LDTA] = 0°) and hindfoot valgus within normal range (0°-10°). SMOT was performed to modify LDTA between 5° valgus, neutral, and 5° varus. In addition, a 10-mm lateral SCO was performed and tested in each position in random order. Axial loading (700 N) of the tibia was applied with the foot in neutral alignment in a customized testing frame. Pressure distribution in the ankle joint and subtalar joint, center of force, and contact area were recorded using high-resolution Tekscan pressure sensors.

Results

At neutral tibial alignment, SCO unloaded the medial joint by a mean of 10% ± 10% or 66 ± 51 N (P = .04) compared with 6% ± 12% or 55 ± 72 N with SMOT to 5° valgus (P = .12). The achieved deload was not significantly different (ns) between techniques. In ankles with 5° varus alignment at baseline, SMOT to correct LDTA to neutral insufficiently addressed pressure redistribution and increased medial load by 6% ± 9% or 34 ± 33 N (ns). LDTA correction to 5° valgus (10° SMOT) unloaded the medial joint by 0.4% ± 14% or 20 ± 75 N (ns) compared with 9% ± 11% or 36 ± 45 N with SCO (ns). SCO was significantly superior to 5° SMOT (P = .017) but not 10° SMOT. The subtalar joint was affected by both SCO and SMOT, where SCO unloaded but SMOT loaded the medial side.

Conclusion

SCO reliably unloaded the medial compartment of the ankle joint for a neutral tibial axis. Changes in the LDTA by SMOT did not positively affect load distribution, especially in varus alignment. The subtalar joint was affected by SCO and SMOT in opposite ways, which should be considered in the treatment algorithm.

Clinical Relevance

SCO may be considered a reliable option for beneficial load-shifting in ankles with neutral alignment or 5° varus malalignment.

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.

Evaluation of clinico-radiological outcome of fibular valgization osteotomy with supra-malleolar osteotomy in patients with ankle osteoarthritis

PURPOSE

There are controversies about combining distal tibia medial opening-wedge osteotomy (DTMO) with fibular valgization osteotomy (FVO) when performing supramalleolar osteotomy (SMO) for medial ankle osteoarthritis. This study aimed to assess the effect of FVO on the coronal translation of the mechanical axis by comparing the improvement of radiological indices after DTMO with and without FVO.

METHODS

Forty-three ankles (mean follow-up: 42.0 months) were reviewed after SMO. Among them, 35/43 (81.4%) underwent DTMO with FVO, while 8/43 (18.6%) underwent DTMO only. To evaluate the effect of FVO radiologically, the medial gutter space (MGS) and talus centre migration (TCM) were measured.

RESULTS

Post-operatively, MGS and TCM were not significantly different after DTMO only and DTMO with FVO. However, the improvement of MGS was significantly higher in the combined FVO group (0.8 mm (standard deviation [SD] 0.8 mm) vs. 1.5 mm (SD 0.8 mm); p = 0.015). More lateral translation of the talus was achieved in the FVO group (5.1 mm (SD 2.3 mm) vs. 7.5 mm (SD 3.0 mm); p = 0.033). However, the changes in the MGS and TCM were not significantly correlated with the clinical outcomes (p > 0.05).

CONCLUSION

Our radiological evaluation confirmed a significant medial gutter space widening and lateral talar translation after the addition of FVO. The SMO with fibular osteotomy allows greater shifting of the talus and, therefore, the weight-bearing axis.

Correction of ankle varus deformity using patient-specific dome-shaped osteotomy guides designed on weight-bearing CT: a pilot study

BACKGROUND

Dome-shaped supramalleolar osteotomies are a well-established treatment option for correcting ankle deformity. However, the procedure remains technically demanding and is limited by a two-dimensional (2D) radiographic planning of a three-dimensional (3D) deformity. Therefore, we implemented a weight-bearing CT (WBCT) to plan a 3D deformity correction using patient-specific guides.

METHODS

A 3D-guided dome-shaped supramalleolar osteotomy was performed to correct ankle varus deformity in a case series of five patients with a mean age of 53.8 years (range 47-58). WBCT images were obtained to generate 3D models, which enabled a deformity correction using patient-specific guides. These technical steps are outlined and associated with a retrospective analysis of the clinical outcome using the EFAS score, Foot and Ankle Outcome Score (FAOS) and visual analog pain scale (VAS). Radiographic assessment was performed using the tibial anterior surface angle (TAS), tibiotalar angle (TTS), talar tilt angle (TTA), hindfoot angle (HA), tibial lateral surface angle (TLS) and tibial rotation angle (TRA).

RESULTS

The mean follow-up was 40.8 months (range 8-65) and all patients showed improvements in the EFAS score, FAOS and VAS (p < 0.05). A 3-month postoperative WBCT confirmed healing of the osteotomy site and radiographic improvement of the TAS, TTS and HA (p < 0.05), but the TTA and TRA did not change significantly (p > 0.05).

CONCLUSION

Dome-shaped supramalleolar osteotomies using 3D-printed guides designed on WBCT are a valuable option in correcting ankle varus deformity and have the potential to mitigate the technical drawbacks of free-hand osteotomies.

LEVEL OF EVIDENCE

Level 5 case series.

Is there an optimal degree of correction for ankle varus deformity after supramalleolar osteotomy? A systematic review

BACKGROUND

There is no consensus on the angle targeted for in varus ankle deformity after supramalleolar osteotomy (SMOT). The aim of this study was to investigate which obtained correction has the best clinical outcome after valgus SMOT.

METHODS

A systematic review according PRISMA guidelines was conducted with studies being eligible for inclusion when published in English, German or Dutch, patients older than 18 years at study entrance, primary or posttraumatic varus ankle osteoarthritis, using any valgus SMOT technique, describing radiological alignment and clinical outcome at baseline and after at least 12 months follow-up. Risk of bias was assessed using the McMaster University Occupational Therapy Evidence-Based Practice Research Group quality assessment tool. The electronical databases PubMed, EMBASE and Cinahl were used as data sources. Included cohorts were categorized according to the mean obtained medial distal tibia angle (MDTA; ranged between 87° and 100°). A linear mixed effect model was used for individual patient data to assess the association between the MDTA and the (difference in) clinical outcome.

RESULTS

Thirty studies including 33 patient cohorts with 922 ankles were identified. At a mean follow-up of 4 years no differences in clinical outcome between correction categories were found. Individual data of 34 ankles showed no relationship between obtained MDTA and clinical outcome either.

CONCLUSION

This review could not demonstrate an optimal degree of correction after valgus SMOT. Results were hampered by biased low quality studies and the widespread use of unreliable 2D alignment measures such as the MDTA.

3D Printing-Assisted Supramalleolar Osteotomy for Ankle Osteoarthritis

Ankle osteoarthritis (OA) is an important factor that causes pain and dysfunction after ankle joint movement. In early and mid-term ankle OA, supramalleolar osteotomy can delay the progression of disease and maximize the preservation of ankle joint function. Three-dimensional printing (3DP) technology has brought us new hope, which can improve the accuracy of osteotomy, reduce the number of fluoroscopy, reduce the amount of blood loss, and achieve personalized and accurate treatment. The data of 16 patients with ankle OA in our center from January 2003 to July 2020 were retrospectively analyzed and divided into the 3DP group and the traditional group according to different treatment methods. Seven patients in the 3DP group used the 3DP personalized osteotomy guide; nine patients were treated by traditional osteotomy. All patients were followed up for 13.9 ± 3.1 months after the operation. The operation time in the 3DP group was 126.4 ± 11.1 min, its intraoperative blood loss was 85.7 ± 24.1 mL, and its intraoperative fluoroscopy time was 2.4 ± 0.2, which were all significantly less than 167.3 ± 12.2 min, 158.3 ± 22.8 mL, and 5.8 ± 0.2 times in the traditional group (P < 0.05), respectively. In the 3DP group, its postoperative tibial anterior surface (TAS) angle was 90.6 ± 0.3° and the talar tilt (TT) angle was 2.2 ± 0.6°, which were all significantly different compared with its preoperative data of 83.4 ± 1.7 and 8.0 ± 1.5°, respectively (P < 0.05). Compared with traditional osteotomy, 3DP-assisted supramalleolar osteotomy for varus and valgus ankle OA can significantly shorten the operation time and reduce intraoperative bleeding and the frequency of intraoperative fluoroscopy; personalized 3DP osteotomy guides and models can assist in the accurate correction of varus deformity during operation, restore the lower limb alignment, and improve the biomechanical status of the lower limbs. In addition, the 3DP of porous tantalum has good histocompatibility, and its interface structure and porosity are more conducive to bone ingrowth. For complex bone defects and revision prostheses, matching implants can be printed individually, which could realize the personalized precise treatment.

Clinical Outcomes of Supramalleolar Osteotomy in Intermediate Stage of Varus Ankle Osteoarthritis in Joint Preservation

Supramalleolar osteotomy (SMO) is an effective treatment for intermediate-stage varus ankle osteoarthritis (OA). This study aimed to investigate how clinical outcomes were associated with radiological changes and cartilage regeneration shown on arthroscopy before and after SMO in patients with intermediate-stage varus ankle OA. Twenty-six cases with intermediate-stage varus ankle OA underwent SMO with at least 1 year of postoperative follow-up. Clinical assessment was performed preoperatively and postoperatively using the visual analog scale (VAS), American Orthopedic Foot and Ankle Society ankle-hindfoot (AOFAS) scores, and their associations with postoperative changes in tibial ankle surface angle (TAS), talar tilt, tibial lateral surface angle, and heel alignment ratio. The degrees of cartilage regeneration in the tibia plafond and talar dome were observed via second-look arthroscopy. Afterward, their associations with the corresponding clinical outcomes were analyzed. There were significant changes in the TAS, talar tilt, and heel alignment ratio (p < .001, for all). However, there were no significant changes in the tibial lateral surface angle (p = .864) at the final follow-up compared to its preoperative value. Postoperative changes in TAS (p = .013) and the degree of cartilage regeneration (p = .028) in the talar dome significantly influenced the final follow-up AOFAS score. Changes in the TAS angle and the degree of cartilage regeneration after SMO were predictors of clinical outcomes after SMO. In particular, greater changes in the TAS angle corresponded to better clinical outcomes.

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.

Supramalleolar Osteotomy vs Arthrodesis for the Treatment of Takakura 3B Ankle Osteoarthritis

BACKGROUND

To compare the clinical/functional outcomes of supramalleolar osteotomy (SMOT) and ankle arthrodesis (AA) for the treatment of modified Takakura stage 3B ankle osteoarthritis.

METHODS

Outcomes of 28 SMOT patients and 30 AA patients were reviewed at an average of 50 and 51 months, respectively. The baseline characteristics of the 2 groups were similar. The preoperative tibial articular surface angle and talar tilt angle in the SMOT group were 82.6 and 10 degrees and in the AA group, 83.9 and 9.1 degrees, respectively. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, visual analog scale (VAS) score, 12-item Short-Form Health Survey (SF-12) mental component summary (MCS) and physical component summary (PCS) scores, range of motion (ROM), radiologic parameters, and complications were compared.

RESULTS

The AOFAS, VAS, and SF-12 MCS and PCS scores improved significantly postoperatively in both groups (P < .001). The VAS and SF-12 PCS scores indicate marginally better improvement in the AA group (P < .05). The patient satisfaction value (P = .028) and the possibility of repeated surgery value (P = .012) were also significantly higher in the AA group. The early (P = .905) and late (P = .181) complications did not significantly differ between the 2 groups. The reoperation rate was significantly higher in the SMOT group (P = .038).

CONCLUSION

Both SMOT and AA showed improvements in function, pain, alignment, and quality of life after surgery. Patients in the AA group reported better pain relief, had a lower reoperation rate, and better hindfoot alignment during a short- to mid-term follow-up time.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Efficacy evaluation and systematic review of supramalleolar osteotomy for treatment of varus-type ankle arthritis

BACKGROUND

The current surgical treatment plan for medium-term varus-type ankle arthritis is primarily supramalleolar osteotomy (SMOT), but the reliability of this procedure still lacks high-quality evidence-based medical studies, such as randomized controlled clinical trials and meta-analyses of comparative studies.

OBJECTIVE

The current study explored whether significant differences were present in the clinical effect, reoperation rate, complications, and failure rate of this type of surgery.

METHOD

Two researchers searched the relevant literature in seven databases, including PubMed, Cochrane Library, EMBASE, the China Biomedical Literature Database, the China Academic Journals Full-text Database, the Wanfang database, and the Weipu Chinese Science and Technology Journal Database. The retrieval time spanned the establishment of the specific database up to September 2020, and the literature was screened to determine their final inclusion in the study.

RESULTS AND CONCLUSIONS

A total of 20 studies were included, including one Chinese and 19 English language studies. The primary indicators included a definitive effect of SMOT on the treatment of medium-term varus-type ankle arthritis. Concerning secondary indicators, although the surgery effect was satisfactory, some patients may require follow-up surgery, which may be unsuccessful with complications. The study results showed that, based on existing literature reports, the effect of SMOT for varus-type ankle arthritis was a satisfactory surgical method with some clinical value for correcting the ankle force line and relieving or even reversing ankle arthritis. However, its risk of complications and failure rate were comparatively high and, accordingly, requires good preoperative planning and close communication with patients. Due to the limited sample size of this study, more data and longer follow-up times involving this type of surgery should be reviewed to confirm this conclusion.

Intra-articular opening wedge osteotomy for varus ankle arthritis with computer-assisted planning and patient-specific surgical guides: a retrospective case series

Background

Computer-assisted preoperative planning, combined with PSI has become an effective technique for treating complex limb deformities. The purpose of this study was to evaluate the efficacy and safety of the novel technique in corrective osteotomy for intra-articular varus ankle deformities associated with osteoarthritis and ankle instability.

Methods

Nineteen patients with intra-articular varus ankle arthritis were reviewed between April 2017 and June 2019, including ten men and nine women with a mean age of 58.3 ± 9.9 years (range, 38 to 76 years). All patients underwent intra-articular opening wedge osteotomy assisted by 3D virtual planning and PSI. Weight-bearing radiographs were used to assess the radiographic results, including TAS angle, TT angle, TMM angle, TC angle, TLS angle, opening-wedge angle, and wedge height. Functional outcomes were assessed by the AOFAS score, VAS score, and ROM of the ankle.

Results

The average follow-up time was 32.2 ± 9.0 months (range, 22 to 47 months). The average union time was 4.4 ± 0.9 months (range, 3.0 to 6.5 months). The TAS angle significantly changed from 84.1 ± 4.6° preoperatively to 87.7 ± 3.1° at the 1-year follow-up and 86.2 ± 2.6° at the latest follow-up. Similarly, the TT angle, TMM angle and TC angle changed significantly at the 1-year follow-up compared with the preoperative assessment and remained stable until the last follow-up. However, the TLS was not corrected significantly. The postoperative obtained opening-wedge angle, and wedge height showed no significant change with preoperative planning. The overall complication rate was 15.8%. The mean VAS score improved from 5.3 ± 0.6 to 2.7 ± 0.7. The mean AOFAS score improved from 56.2 ± 7.6 to 80.6 ± 4.6. However, the ROM showed no significant change.

Conclusions

Accurate correction and satisfactory functional recovery were attained with computer-assisted planning and PSI in the corrective osteotomy of intra-articular varus ankle deformities.

Supplementary information

The online version contains supplementary material available at 10.1186/s12891-022-05437-z.

Joint-Preserving Surgery in Varus Ankle Osteoarthritis

Ankle deformity is a disabling condition especially if concomitant with osteoarthritis (OA). Varus ankle OA is one of the most common ankle OA deformities. This deformity usually leads to unequal load distribution in the ankle joint and decreases joint contact surface area, leading to a progressive degenerative arthritic situation. Varus ankle OA might have multiple causative factors, which might present as a single isolated factor or encompassed together in a single patient. The etiologies can be classified as post-traumatic (e.g., after fractures and lateral ligament instability), degenerative, systemic, neuromuscular, congenital, and others. Treatment options are determined by the degree of the deformity and analyzing the pathology, which range from the conservative treatments up to surgical interventions. Surgical treatment of the varus ankle OA can be classified into two categories, joint-preserving surgery (JPS) and joint-sacrificing surgery (JSS) as total ankle arthroplasty and ankle arthrodesis. JPS is a valuable treatment option in varus ankle OA, which should not be neglected since it has showed a promising result, optimizing biomechanics and improving the survivorship of the ankle joint.

Dome Supramalleolar Osteotomies for the Treatment of Ankle Pain with Opposing Coronal Plane Deformities Between Ankle and the Lower Limb

BACKGROUND

The dome-type osteotomy is a powerful technique for deformity correction of the limb. However, there is limited information about the utility of dome supramalleolar osteotomy (SMO) in ankle joint preservation surgery. This study aimed to describe the technique and indications for dome SMO in distal tibial malalignment.

METHODS

Twenty-three patients (23 ankles) who underwent dome SMO with a 2-year follow-up were reviewed. Dome SMO was indicated when there were opposing deformities in the ankle and lower limb mechanical axis (ie, varus ankle deformity with valgus lower limb alignment and vice versa) where inherent translation following conventional wedge-type osteotomies could worsen the deformity of the entire lower limb. Patients were divided into 2 groups based on preoperative ankle alignment: the varus ankle group (n = 11) and the valgus ankle group (n = 12). The radiographic correction was assessed using 6 parameters from weightbearing ankle and hindfoot alignment views. In addition, the lower limb mechanical axis was assessed with ankle center deviation (ACD) from the hip-knee (HK) line on the whole limb radiograph, and the weightbearing line (WBL) point was measured to identify changes in the weightbearing load within the ankle joint.

RESULTS

Preoperatively, the varus ankle group had varus ankle deformity (tibiotalar angle [TTA], 76.5 ± 5.8 degrees) with valgus lower limb mechanical axis, whereas the valgus ankle group had valgus ankle deformity (TTA, 99.1 ± 4.5 degrees) with varus lower limb mechanical axis alignment. Postoperatively, a significant improvement in the ankle alignment and the lower limb mechanical axis was observed in both groups. The ACD significantly changed toward the HK line, suggesting an improved lower limb mechanical axis, and the WBL point showed a significant shift of the weightbearing axis toward the uninvolved area within the ankle joint.

CONCLUSION

Dome SMO demonstrated a successful correction of local deformity while simultaneously realigning the hip-knee-ankle axis toward neutral. Additionally, an effective load shifting toward an uninvolved area within the ankle joint was observed.

LEVEL OF EVIDENCE

Level IV, case series.

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.

[Conversion osteotomy for arthrosis of the ankle joint (supramalleolar and inframalleolar)-What can be expected? : Critical review of the literature]

The aim of supramalleolar conversion osteotomy is to reduce the pain of the patient and stop or at least slow down joint degeneration. The indication for supramalleolar osteotomy is asymmetric osteoarthritis of the ankle joint with varus or valgus deformity. Good clinical results for arthritis can be achieved in the early or middle stages. Besides closing and opening wedge osteotomies dome osteotomy is sometimes indicated, especially for larger deformities. The preoperative preparation of individual patient-specific section blocks facilitates the intraoperative implementation and seems to increase the precision. Further studies are necessary to support this. The indications for additional procedures, such as fibular osteotomy are still being discussed. Inframalleolar osteotomy and soft tissue interventions are frequently necessary for balancing the foot.

Osteotomy combined with lateral ligament reconstruction in treating osteochondral lesion in patients with talar injury and varus ankle

This study aimed to investigate the therapeutic effects of osteotomy combined with lateral ligament reconstruction on the osteochondral lesion of patients with talar injuries and varus ankles.Seventy five patients with talar injuries and varus ankles who received osteotomy combined with lateral ligament reconstruction for the osteochondral lesions from June 2008 to December 2014 were retrospectively reviewed. Patients were followed up for 32.4 ± 15.3 months after surgeries, and the AOFAS-AH score, VAS score and SF36 score were determined preoperatively and postoperatively. The iconographic data were compared preoperatively and postoperatively, including tibial anterior surface angle (TAS), TTS, TT, and tibial lateral surface angle (TLS) angles.After surgeries, the AOFAS-AF score increased from 43.2 ± 8.1 to 82.1 ± 5.6, the VAS score decreased from 6.9 ± 2.3 to 1.8 ± 1.5, and the SF36 score increased from 48.7 ± 9.4 to 83.5 ± 6.2. TAS increased from 83.3 ± 5.1 to 90.3 ± 6.1, TTS increased from 70.3 ± 6.1 to 82.5 ± 5.4, TT decreased from 12.9 ± 6.1 to 6.9 ± 5.7, and TLS increased from 76.5 ± 4.1 to 81.2 ± 3.3 (P < .05).Osteotomy combined with lateral ligament reconstruction is effective for the treatment of talar osteochondral lesion with varus ankle, which could relieve the arthritic symptoms induced by cartilage lesions. By correcting the force line on lower limbs and metapedes with osteotomy completely, the treatments on talar osteochondral lesion and lateral ligament reconstruction are the critical factors with better results.

Endoprothetik am oberen Sprunggelenk

Arthrosis of the upper ankle is usually the long-term consequence of an ankle fracture. In the case of advanced osteoarthritis - after all conservative therapy options have been exhausted - the therapeutical options are reduced to the choice between arthrodesis and prosthesis, the technique and follow-up treatment of which this article presents. The mobility achieved after endoprosthetic treatment is usually less than the normal physiological level, but still functionally sufficient.

What Are the Indications for Implant Revision in Three-component Total Ankle Arthroplasty?

BACKGROUND

Given the increasing usage of total ankle arthroplasty (TAA), a better understanding of the reasons leading to implant revision and the factors that might influence those indications is necessary to identify at-risk patients.

QUESTION/PURPOSES

Using a single-design three-component ankle prosthesis, we asked: (1) What is the cumulative incidence of implant revision at 5 and 10 years? (2) What are the indications for implant revision in our population? (3) What factors are associated with an increased likelihood of implant revision during the time frame in question?

METHODS

Between 2003 and 2017, primary TAA using a single-design three-component ankle implant was performed by or under the supervision of the implant designer in 1006 patients (1074 ankles) aged between 17 and 88 years to treat end-stage ankle osteoarthritis. No other TAA systems were used during the study period at the investigators' institution. In 68 patients with bilateral surgery, only the first TAA was considered. Of the patients treated with the study implant, 2% (16 of 1006) were lost to follow-up 5 to 14 years after TAA and were not known to have died or undergone revision, and 5% (55 of 1006) were deceased due to reasons unrelated to the procedure, leaving 935 patients for evaluation in this retrospective study. The mean (range) follow-up for the included patients was 8.8 ± 4.2 (0.2 to 16.8) years. Implant revision was performed 0.5 to 13.2 years after TAA in 12% (121 of 1006) of our patients. Survivorship free from revision was calculated using cumulative incidence (competing risks) survivorship, with death as a competing risk. The reason for each revision was classified into one of six categories according to a modified version of a previously published protocol: aseptic loosening, cyst formation, instability, deep infection, technical error, and pain without another cause. Two foot and ankle surgeons reviewed the records of all patients who underwent implant revision and assigned each patient's reason for revision to one of the six categories. The decision for assigning each patient to one of the six categories was made based on a consensus agreement. A subgroup classification of preoperative ankle alignment (neutral, mild, and major deformity) and variables of age, sex, BMI, etiology of ankle osteoarthritis, and number of preoperative and intraoperative hindfoot or midfoot procedures were used in a multinomial logistic regression and Cox regression analysis to estimate their association with reason for revision and implant survival until revision.

RESULTS

The cumulative incidence of implant revision at the mean (range) follow-up time of 8.8 ± 4.2 years (0.2 to 16.8) was 9.8% (95% confidence interval 7.7% to 11.8%). Five and 10 years after TAA, cumulative incidence was 4.8% (95% CI 3.4 to 6.1) and 12.1% (95% CI 9.7% to 14.5%), respectively. The most common reason for revision was instability (34% [41 of 121]), followed by aseptic loosening of one or more metallic components (28% [34 of 121]), pain without another cause (12% [14 of 121]), cyst formation (10% [12 of 121]), deep infection (9% [11 of 121]), and technical error (7% [9 of 121]). Ankles with a major hindfoot deformity before TAA were more likely to undergo revision than ankles with a minor deformity (hazard ratio 1.9 [95% CI 1.2 to 3.0]; p = 0.007) or neutral alignment (HR 2.5 [95% CI 1.5 to 4.4]; p = 0.001). A preoperative hindfoot valgus deformity increased revision probability compared with a varus deformity (HR 2.1 [95% CI 1.4 to 3.4]; p = 0.001).

CONCLUSION

Instability was a more common reason for implant revision after TAA with this three-component design than previously reported. All causes inducing either a varus or valgus hindfoot deformity must be meticulously addressed during TAA to prevent revision of this implant. Future studies from surgeons/institutions not involved in this implant design are needed to confirm these findings and to further investigate why a substantial number of patients had pain of unknown cause prompting revision.

LEVEL OF EVIDENCE

Level III, therapeutic study.

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.

3D Assessment in Posttraumatic Ankle Osteoarthritis

BACKGROUND

Auto-generated 3-dimensional (3D) measurements based on weightbearing cone-beam computed tomography (CT) scan technology may allow for a more accurate hind- and midfoot assessment. The current study evaluated the reliability and clinical relevance of such measurements in patients with posttraumatic end-stage ankle osteoarthritis.

METHODS

Seventy-two patients treated at our institution for posttraumatic end-stage ankle osteoarthritis, with available weightbearing conventional radiographs and a cone-beam CT scan, were analyzed. Twenty healthy individuals aged between 40 and 70 years served as controls. Seven variables were measured on weightbearing conventional radiographs (2D) and compared to 3D measurements that were based on reconstructions from weightbearing cone-beam CT scans. The reliability of each measurement was calculated and subgroups formed according to commonly observed deformities.

RESULTS

Inter- and intraobserver reliability was superior for 3D compared to 2D measurements. The accuracy of 3D measurements performed on osteoarthritic ankles was similar to 3D measurements performed on healthy individuals. Thirty-three of the 72 included patients (46%) evidenced an inframalleolar compensation of a supramalleolar/intra-articular ankle deformity (78% = varus compensation; 22% = valgus compensation), whereas 24 of those 72 patients (33%) showed no compensation or a further increase of a supramalleolar/intra-articular ankle deformity (67% = varus deformity; 33% = valgus deformity).

CONCLUSION

Auto-generated 3D measurements of the hind- and midfoot were found to be reliable in both healthy individuals and patients with posttraumatic end-stage ankle osteoarthritis. Such measurements may be crucial for a detailed understanding of the location and extent of hindfoot deformities, possibly impacting decision making in the treatment of end-stage ankle osteoarthritis.

LEVEL OF EVIDENCE

Level III, comparative study.

Hindfoot balancing in total ankle replacement: the role of supramalleolar osteotomies

PURPOSE

To compare the obtained deformity correction and clinical/functional outcomes between patients who underwent total ankle replacement (TAR) with or without a concurrent supramalleolar osteotomy (SMO) to address a varus and/or recurvatum deformity of the distal tibia.

METHODS

Data of 23 patients treated with an additional SMO to correct a varus and/or recurvatum deformity of the distal tibia at the time of TAR were prospectively collected. Twenty-three matched patients who underwent TAR only served as controls.

RESULTS

The American Orthopaedic Foot and Ankle Society (AOFAS)-hindfoot scale and pain assessed on a Visual Analogue Scale (VAS) did not significantly differ between the two groups at the final follow-up (AOFAS-hindfoot scale SMO/TAR group = 82 ± 10; TAR group = 82 ± 12; VAS pain SMO/TAR group = 1 (range, 0-4); TAR group = 1 (range, 0-5)). Ankle range of motion (ROM) did not improve in the SMO/TAR group (pre-operative = 27 ± 13 degrees, last follow-up = 30 ± 9 degrees; P = .294), but did improve in the TAR group (pre-operative = 31 ± 14 degrees, last follow-up = 39 ± 14 degrees; P = .049). Two patients who underwent SMO/TAR showed non-union of the tibial osteotomy, and two patients who underwent TAR only suffered from an intra-operative medial malleolar fracture.

CONCLUSION

An additional SMO during TAR in patients with a varus and/or recurvatum deformity of the distal tibia is not beneficial in most cases and should only be considered in pronounced multiplanar deformities.

Supramalleolar osteotomy in post-traumatic valgus ankle osteoarthritis

PURPOSE

To assess how the level of the deformity, the stage of the osteoarthritic process, and the role of additional surgeries impact radiographic and clinical outcomes following an extra-articular medial closing supramalleolar osteotomy for treatment of post-traumatic valgus ankle osteoarthritis.

METHODS

About 56 consecutive patients who underwent an extra-articular medial closing wedge osteotomy for post-traumatic valgus ankle osteoarthritis were retrospectively analyzed. Subgroups were formed according to the pre-operative level of deformity and preoperative stage of ankle osteoarthritis. Additional surgical steps required to achieve a properly balanced hindfoot were also noted. Radiographic and clinical outcomes of each subgroup were compared with each other, and the role of additional surgical steps required to achieve a balanced hindfoot was investigated.

RESULTS

Radiographic and clinical outcomes improved significantly between pre-operative assessment and the last follow-up. Patients with a pre-operative supramalleolar deformity showed superior radiographic outcomes compared to patients with an intra-articular deformity. Clinical outcomes did not differ significantly between these two subgroups. The pre-operative stage of ankle osteoarthritis significantly impacted radiographic outcomes but did not influence clinical outcome measures. An additional fibula or calcaneus osteotomy was necessary for 55% and 23% of all patients, respectively.

CONCLUSION

Extra-articular medial closing supramalleolar osteotomies show satisfactory mid- to long-term radiographic and clinical outcomes in patients with post-traumatic valgus ankle osteoarthritis.