Supramalleolar osteotomy with medial distraction arthroplasty for ankle osteoarthritis with talar tilt

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.

Forsythoside B alleviates osteoarthritis through the HMGB1/TLR4/NF-κB and Keap1/Nrf2/HO-1 pathways

Osteoarthritis (OA) is a joint pain and dysfunction syndrome resulting from severe joint degeneration. Inflammation and degeneration of the articular cartilage are two main features of OA and have tight interactions during OA progression. Conventional treatment with nonsteroidal anti-inflammatory drugs has been widely utilized clinically, whereas the side effects have restricted their application. Forsythoside B has been found with anti-inflammatory effects and antiapoptosis in inflammatory diseases, whereas in OA it remains poorly understood. Interleukin (IL)-1β (10 ng/mL) was taken to induce an OA cell model on HC-A chondrocytes and an OA rat model was constructed for in vivo experiments. Forsythoside B was adopted to treat HC-A chondrocytes and OA rats. As shown by the data, Forsythoside B hampered IL-1β-elicited rat chondrocyte apoptosis, oxidative stress, and facilitated proliferation. The profiles of inflammatory factors, NOD-like receptor family pyrin domain containing 3 inflammasomes, Kelch-like epichlorohydrin-associated protein-1 (Keap1), and nuclear factor-κB (NF-κB) phosphorylation were suppressed by Forsythoside B, whereas the nuclear factor E2-related factor 2 (Nrf2) and heme oxygenase-1 (HO-1) levels were promoted. Further, Forsythoside B mitigated cartilage damage and degeneration. Moreover, the oxidative stress and inflammation mediators in the cartilage tissue of OA rats were remarkably abated. Collectively, Forsythoside B hinders the NF-κB and Keap1/Nrf2/HO-1 pathways to curb IL-1β-elicited OA rat oxidative stress and inflammation both in vivo and ex vivo, ameliorating OA development. All over, this study provides an underlying strategy for treating OA, which might help the clinical treatment of OA patients.

Ankle Distraction Arthroplasty: A Survivorship Review and Meta-Analysis

Multiple treatments exist for ankle osteoarthritis. Ankle arthrodesis is the gold standard in late-stage osteoarthritis, but sacrifices range of motion and risks nonunion. Total ankle arthroplasty is typically reserved for low-demand patients as the long-term outcomes are poor. Ankle distraction arthroplasty is a joint sparing procedure which utilizes external fixator frame to unload the joint. This promotes chondral repair and improves function. This study aimed to organize clinical data and survivorship in published papers and direct further research efforts. Thirty-one publications were evaluated and 16 were included in the meta-analysis. The Modified Coleman Methodology Score was used to assess quality of the individual publications. Random effects models were used to estimate the failure risk after ankle distraction arthroplasty. Ankle Osteoarthritis Score (AOS), American Orthopedic Foot and Ankle Score (AOFAS), Van Valburg, and Visual Analog Scores (VAS) all improved postoperatively. Random effects model analysis revealed an overall failure ratio of 11% (95% CI: 7%-15%; p value ≤ .001; I2 = 87.01%) after 46.68 ± 7.17 months follow up, 9% (95% CI: 5%-12%; p value≤0.001 I2=81.59%) with less than 5 years follow-up and 28% (95% CI: 16%-41%; p value≤0.001 I2=69.03%) for patients with more than 5 years follow-up. Ankle Distraction Arthroplasty has promising short to intermediate term outcomes which makes this a reasonable treatment option to delay joint sacrificing surgery. The selection of the optimal candidates and consistent technique would improve research and subsequently outcomes. Based on our meta-analysis, negative prognostic factors include female sex, obesity, ROM < 20°, leg muscle weakness, high activity level, low preoperative pain levels, higher preoperative clinical scores, inflammatory arthritis, septic arthritis, and deformity.

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 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.

Supramalleolar osteotomy for the treatment of ankle osteoarthritis leads to favourable outcomes and low complication rates at mid-term follow-up: a systematic review

PURPOSE

The purpose of this systematic review was to evaluate both the clinical and radiographic outcomes following supramalleolar osteotomy (SMO) in patients with ankle osteoarthritis, and to analyse the level of evidence (LOE) and quality of evidence (QOE) of the included studies.

METHODS

A systematic review of the MEDLINE, EMBASE, and Cochrane Library databases was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting clinical data following SMO for the treatment of ankle osteoarthritis were included and assessed. The level and quality of evidence of the included studies were also evaluated.

RESULTS

Twenty-four studies with 1160 patients (1182 ankles) were included. Overall, 78.8% patients presented with post-traumatic ankle osteoarthritis. The weighted mean AOFAS score improved from 52.6 ± 9.7 (range 33.8-78.4) preoperatively to 78.1 ± 5.7 postoperatively at weighted mean follow-up of 50.4 ± 18.6 months (range 24.5-99.0).  The most frequently utilised radiographic parameter was the tibial anterior surface angle, which improved from a preoperative weighted mean of 86.3° ± 5.6° (range 76.0°-102.0°) to a postoperative weighted mean of 89.9° ± 3.7° (range 84.9°-99.6°). The complication rate was 5.1% with non-union as the most commonly reported complication (1.6%). Secondary procedures were carried out in 28.2% of patients, the most common of which was implant and hardware removal (17.6%). The failure rate was 6.8%. Two studies were LOE II, 3 studies were LOE III, and 19 studies were LOE IV. The mean Modified Coleman Methodology Score was 59.3 ± 6.6 and the mean MINORS criteria score of all the included studies was 9.5 ± 3.7.

CONCLUSION

This systematic review demonstrates good clinical and radiological outcomes, together with a low failure rate at mid-term follow-up following supramalleolar osteotomy in patients with ankle osteoarthritis. However, a moderate reoperation rate (28.2%) was reported. A low failure rate (6.8%) was reported, which must be interpreted in light of the shortcomings of the design of the included studies and a relatively short follow-up period. In addition, there is a low level and quality of evidence in the current literature with inconsistent reporting of data which underscores the need for further higher quality research to be conducted. Our review highlights that SMO may be an effective and safe procedure in the setting of early-to-intermediate-stage ankle osteoarthritis.

LEVEL OF EVIDENCE

IV.

Short-Term Clinical Outcomes Following Total Ankle Arthroplasty Without Concomitant Osteotomy in Ankles with Severe Preoperative Varus Deformity: Comparison to Ankles with Preoperative Neutral Alignment

BACKGROUND

It remains controversial whether satisfactory outcomes can be obtained following total ankle arthroplasty (TAA) without osteotomy in patients with severe varus ankle deformities. This study aimed to examine outcomes following TAA without concomitant osteotomies in patients with severe varus ankle alignment by comparing them with those in patients with neutral alignment.

METHODS

Fifty-one patients (53 ankles; mean age, 71.4 ± 5.6 years) who underwent TAA using the TNK ankle prosthesis were examined (mean follow-up, 36.8 ± 17.8 months). Patients were allocated into groups according to the preoperative talar tilt (TT) angle: the neutral group (preoperative TT angle <10°; n = 37) and the varus group (preoperative TT angle ≥10°; n = 16). Outcome measures, including the Japanese Society for Surgery of the Foot scale, Self-Administered Foot Evaluation Questionnaire, ankle range of motion, and radiographic parameters, were assessed before surgery and at the final follow-up.

RESULTS

Significant improvements were observed in clinical and radiographic outcomes in both groups after surgery. Postoperative Japanese Society for Surgery of the Foot scale and subscale scores of pain and shoes in the Self-Administered Foot Evaluation Questionnaire were not significantly different between the groups, whereas subscale scores of function, social, and health were greater in the varus group than in the neutral group at the final follow-up. Radiographic parameters, including TT angle and tibial axis-medial malleolus (TMM) angle, improved postoperatively and were not significantly different between the neutral (mean TT angle, 0.5 ± 0.7°; mean TMM angle, 16.0 ± 4.6°) and varus (meanTT angle, 0.4 ± 0.7°; meanTMM angle, 17.0 ± 5.3°) groups at the final follow-up. To achieve neutral alignment, adjunctive procedures were required more often in the varus group.

CONCLUSIONS

Outcomes of TAA using the TNK ankle prosthesis were favorable in patients with severe varus ankle and in those with neutral ankle without concomitant osteotomy. Satisfactory outcomes could be achieved in patients with severe varus ankle alignment after TAA without concomitant osteotomy.

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.

Distraction arthroplasty in the management of osteoarthritis of the ankle: A systematic review

BACKGROUND

This study aimed to evaluate the use of distraction arthroplasty for ankle osteoarthritis, with respect to patient reported outcome measures (PROMs), complications, range of motion and radiographic outcomes.

METHODS

A computer-based search was performed in PubMed, Cinahl, Embase, Scopus and ISI Web of Science. Two reviewers independently performed title/abstract and full-text screening. Quality assessment was performed using The Methodological Index for Non-Randomised Studies (MINORS) and Joanna Briggs Institute criteria.

RESULTS

Whilst all studies evaluating PROMs reported significant (P < 0.05) improvement, these were either below or only slightly above the minimally clinically important difference. The rate of conversion to arthrodesis or total ankle arthroplasty was high, with failure rates of up to 52% reported.

CONCLUSION

Due to the inconsistent improvements in PROMs, which are likely overestimated due to substantial bias, and the high failure rate, this review suggests that distraction arthroplasty is not currently an effective treatment option for ankle arthritis.

LEVEL OF EVIDENCE

Level IV, systematic review of level I to IV studies.

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.

Ankle distraction arthroplasty (ADA): A brief review and technical pearls

Ankle distraction arthroplasty (ADA) is a procedure based on the concept that mechanical unloading of an arthritic joint will initiate a healing response in the subchondral bone and articular cartilage. ADA utilizes the patient's own healing response, preserves joint motion, and is a great option for patients with osteoarthritis who are not ready for prosthetic arthroplasty or fusion. The procedure is well described and technically simple and adjunctive biologic therapies are exciting for joint regeneration. Complications are minor, and more serious adverse events are avoidable. Supramalleolar osteotomy pairs well with ankle distraction but requires some analysis and planning.

Fibular osteotomy is helpful for talar reduction in the treatment of varus ankle osteoarthritis with supramalleolar osteotomy

BACKGROUND

There have been debates on the necessity of fibular osteotomy (FO) in supramalleolar osteotomy (SMOT) for the treatment of varus ankle osteoarthritis. The purpose of the current study was to compare the clinical and radiological outcomes between SMOT with and without FO in the treatment of varus ankle osteoarthritis.

METHODS

The SMOT group included 39 patients, and the SMOT with FO group included 24 patients. The basic information reached no significant difference between groups. The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Ankle Osteoarthritis Scale (AOS), modified Takakura stage and range of motion (ROM) were used for the functional evaluation. The radiologic parameters were assessed at the last follow-up to compare the degree of talar reduction between the two groups.

RESULTS

Both groups achieved significant improvements in AOFAS scores, modified Takakura stage, as well as AOS pain and functional scores (P < 0.001). The ROM of the ankle joint in the SMOT group was significantly decreased (P = 0.022). In both groups, all of the radiological parameters were significantly improved (P < 0.01). The tibiofibular clear space (TFCS) was significantly widened in the SMOT group (P < 0.001). No significant difference was found between the two groups according to the functional outcomes. However, the talar tilt angle (TT) and hindfoot alignment angle (HFA) in the SMOT with FO group were significantly smaller than those in the SMOT group (P < 0.05). The TFCS was significantly widened in the SMOT group (P = 0.001). The medial displacement of the talus (MDT) was better reduced in the SMOT with FO group (P = 0.006).

CONCLUSION

SMOT is a promising procedure for functional improvement and malalignment correction in varus ankle osteoarthritis but reduces ankle range of motion. If SMOT is combined with FO, talar tilt and medial displacement will be better reduced.

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.

Simulated operation combined with patient-specific instrumentation technology is superior to conventional technology for supramalleolar osteotomy: a retrospective comparative study

OBJECTIVE

Over the past seven years, our team has designed a simulated operation combined with patient-specific instrumentation (SO-PSI) assisted supramalleolar osteotomy (SMOT) method and applied it in the clinic. This study aimed to evaluate the differences between SO-PSI technology and conventional operation (CO) technology for SMOT in preoperative planning, intraoperative application, and postoperative curative effect.

METHODS

We retrospectively analyzed SMOT data collected from our hospital between October 2014 and December 2018. Patients (n = 28) were enrolled and divided into CO (n = 17) and SO-PSI (n = 11) groups; mean follow-up time was 33.4 (range, 13 to 59) months. We statistically analyzed and compared perioperative data, accuracy of preoperative planning, intraoperative application, difference between pre- and post-operative radiologic ankle angles, changes in American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analogue scale (VAS) score, range of ankle motion, and Takakura stage after surgery.

RESULTS

All ankle alignments and positions were recovered for both groups. Compared with the CO group, the SO-PSI group had a shorter mean operating time and postoperative hospital stay, a decreased number of fluoroscopy examinations, lower albumin reduction, longer preoperative planning time and preoperative hospital stay, and increased hospitalization expenses. In the SO-PSI group, comparison of ankle angles at preoperative planning and postoperatively revealed good correlation, while this was not the case in the CO group. Mean tibial ankle center discrepancy for the SO-PSI group was 1.86 ± 1.06 mm. On follow-up, all radiologic parameters for the two groups improved significantly; however, the improvement of the tibial anterior surface angle and tibiotalar tilt angle for the SO-PSI group were more obvious than those for the CO group. AOFAS score, VAS score, ankle range of motion, and Takakura stage improved after surgery in both groups; however, the improvements in the SO-PSI group were greater than those in the CO group overall.

CONCLUSIONS

SO-PSI technology can facilitate accurate and rapid preoperative planning for SMOT. In general, compared with conventional technology, SO-PSI has advantages for preoperative planning, intraoperative application, and postoperative curative effect.

Ankle distraction arthroplasty for the treatment of severe ankle arthritis: Case report, technical note, and literature review

RATIONALE

Widely applied in the treatment of severe ankle arthritis (AA), ankle distraction arthroplasty (ADA) can avoid not only the ankle range of motion loss but also ankle fusion. However, the clinical outcomes of ADA for severe AA are poorly understood. This study aims to present our clinical outcomes of severe AA treated by ADA.

PATIENT CONCERNS

A 53-year-old man suffered right ankle sprain 10 years ago, endured right ankle pain and limited movement for 6 years.

DIAGNOSIS

The patient was diagnosed as severe AA.

INTERVENTIONS

He received ankle distraction arthroplasty. No adjuvant procedures were performed. The visual analog scale (VAS), the American Orthopaedic Foot and Ankle Society (AOFAS) score, the short-form (SF)-36 physical component summary (PCS) score and ankle activity score (AAS) were recorded to access the clinical outcomes pre- and postoperatively. Moreover, ankle joint space distance was evaluated on weight-bearing radiographs.

OUTCOMES

The patient derived effective pain relief and restored a satisfactory range of movement. There was a 13-month follow-up period after frame removal. The AOFAS score improved from 56 preoperatively to 71 postoperatively. The VAS score decreased from 6 prior to surgery to 1 after surgery. The SF-36 PCS was 47.2 and 71.8 pre- and postoperative, respectively. The AAS scores were improved from 3.4 preoperatively to 7.3 postoperatively.

LESSONS

ADA is reliable to achieve pain relief, functional recovery, and serve AA resolution. Besides, it is an alternative to ankle arthrodesis or total ankle arthroplasty in selected patients with severe AA.

Low Tibial Valgization Osteotomy for More Severe Varus Ankle Arthritis

BACKGROUND

Low tibial valgization osteotomy with medial opening wedge (LTO) is generally indicated for ankle arthritis with a small talar tilt (TT). We addressed the following research questions: the efficacy of LTO for more significant varus ankle arthritis, the effect of additional inframalleolar correction followed by LTO, and the preoperative or operation-related factors influencing postoperative TT decrease.

METHODS

We retrospectively reviewed the radiographic and clinical findings of 31 patients with more significant varus ankle arthritis (≥8 degrees) who underwent LTO or LTO plus inframalleolar correction. We grouped the included patients according to combination with inframalleolar correction and postoperative decreased TT. Furthermore, a binary logistic regression analysis was performed to determine the factors influencing postoperative TT decrease.

RESULTS

Even though the mean TT was unchanged postoperatively (from 12.1 to 9.9 degrees, P = .052), clinical parameters were significantly increased. In the group with concomitant inframalleolar correction, we found that TT was more corrected (3.9 vs 1.8 degrees, P = .023) with a greater lateralization of the talar center and a greater correction of the hindfoot alignment to valgus. The results of the binary logistic regression analysis showed a significant relationship between postoperative decreased TT and preoperative talar center migration (P = .016), hindfoot alignment angle (P = .033), hindfoot moment arm (P = .041), and hindfoot alignment ratio (P = .016).

CONCLUSION

LTO in more significant varus ankle arthritis could result in clinical improvement, although TT was not significantly changed. We recommend adding inframalleolar correction after LTO for the patients with more significant varus ankle arthritis.

LEVEL OF EVIDENCE

Level III, comparative series.