Medial malleolar osteotomy for the correction of varus deformity during total ankle arthroplasty: results in 15 ankles

BACKGROUND: Preoperative deformity in the frontal plane in the arthritic ankle is a risk factor for failure after total ankle arthroplasty. Medial malleolar lengthening osteotomy was developed to correct varus malalignment. MATERIALS AND METHODS: From 1998 to 2005 total ankle arthroplasty combined with medial malleolar lengthening osteotomy was done in 15 ankles (13 patients) with a mean preoperative varus deformity of 14.9 (SD, 7.8) degrees. Diagnosis was arthritis with instability in 11 ankles (9 patients) and inflammatory joint disease in 4 ankles. Two mobile-bearing designs were used. Osteosynthesis of the osteotomy was done in 2 ankles; for the remaining 13 osteotomies, no fixation was used. RESULTS: Followup was 5 (range 2 to 8) years. Neutral alignment was obtained in all ankles. In 3 patients residual hindfoot varus remained, for which a second-stage hindfoot correction was done. Two rheumatoid ankles developed a symptom-free nonunion of the medial malleolus, all other malleolar osteotomies united. One tibial component, implanted with too much anterior slope, developed early aseptic loosening and was revised. Debridement for talar-malleolar arthritis was done in two ankles. Of the 14 ankles in followup, 12 were rated as excellent or good, one as fair. One ankle with subsidence of the talar component was rated as unsatisfactory. AOFAS score increased from 30.8 preoperative to 81.0 at followup (p < 0.01). CONCLUSION: Medial malleolar lengthening osteotomy is an easy technique for the realignment of the varus ankle at the time of total ankle arthroplasty, and served as an alternative to medial ligament release or lateral ligament reconstruction.     

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

BackgroundThere 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.MethodsA 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.ResultsThirty 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.ConclusionThis 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.     

Transphyseal osteotomy of the distal tibia for correction of valgus/varus deformities of the ankle

This study is a retrospective review of the results of consecutive cases of a transphyseal osteotomy of the distal tibia. Indications for the procedure are significant valgus or varus deformities of the ankle needing acute correction because of problems with the skin and brace fit as well as progressive deformity. Twenty-one patients with a variety of underlying diagnoses, five with bilateral deformities, underwent this procedure. The technique involved making either a medially based closing or opening wedge with the distal limb of the osteotomy through the physis or the physeal scar so that it was very close to the ankle joint. A fibular osteotomy was not necessary except in three ankles. All osteotomies healed. All patients were able to ambulate and use their braces as soon as their osteotomies healed, and none had any further pressure sores or brace-related problems, although some had mild residual valgus or varus deformities. There were no significant leg-length discrepancy problems as a result of the surgery. This osteotomy is a treatment alternative for significant angular deformities of the ankle that require acute correction.     

Medial malleolar osteotomy for the correction of tibiotalar varus deformity during total ankle arthroplasty: Results in 95 ankles

BackgroundThe importance of deformity correction before or during total ankle replacement (TAR) has been recognized for a long time. Our results of TAR, combined with medial malleolar lengthening osteotomy, for the reconstruction of osteoarthritic ankles with varus deformity are hereby reported.MethodsAll ankles in which a medial malleolar osteotomy was performed during implantation of an ankle prosthesis during the period 1998–2018 were filtered out of our database. Preoperative coronal talar alignment was evaluated by measuring the angle between the tibial shaft and talar dome on the weightbearing mortise ankle radiograph. Patient-reported outcomes were measured with the Foot and Ankle Outcome Score (FAOS) and the Foot and Ankle Ability Measure (FAAM). A Kaplan-Meier survival curve was constructed and the number of revisions per 100 observed component years was calculated for interprosthetic comparison.ResultsA total of 95 TARs were included, consisting of the Alpha Ankle Arthroplasty (n = 22); Buechel-Pappas (n = 14) and the Ceramic Coated Implant Evolution (n = 59) prostheses. The preoperative average talar angle in these ankles was 12.4 degrees varus. In 33% (31/95) corrective procedures, in addition to the medial malleolar osteotomy, were performed. A reoperation rate of 44% (42/95) was found, including 28 revisions (revision rate 29% (4% septic; 25% aseptic) at an average follow-up of 5.9 years, resulting in a survival of 0.69 for the total cohort at 10 years of follow-up.At an average follow-up of 6.6 years the average FAOS scores were: FAOS_symptoms 66, FAOS_pain 73, FAOS_function 78, FAOS_sport 45 and FAOS_{quality of life} 56 respectively. The FAAM_adl score averaged 64.ConclusionThis is the largest cohort of TAR combined with medial malleolar osteotomy to date. A 29% revision rate at 5.9 years of average follow-up compares unfavorably with regular cohort studies and with most other results in varus-deformed ankles. Scores on the FAOS and FAAM are comparable to those obtained in regular cohorts with similar length of follow-up. TAR in varus-deformed ankles necessitating medial malleolar osteotomy has an even higher failure rate than regular TAR. Obtaining a stable prosthesis with a neutrally-aligned hindfoot at the end of the procedure is of paramount importance.Level of evidenceIV.     

Distal Chevron Osteotomy with Lateral Soft Tissue Release for Moderate to Severe Hallux Valgus Decided Using Intraoperative Varus Stress Radiographs

The purpose of the present study was to investigate the outcomes of distal chevron osteotomy with lateral soft tissue release for moderate to severe hallux valgus. The patients were selected using criteria that included the degree of lateral soft tissue contracture and metatarsocuneiform joint flexibility. The contracture and flexibility were determined from intraoperative varus stress radiographs. From April 2007 to May 2009, 56 feet in 51 consecutive patients with moderate to severe hallux valgus had undergone distal chevron osteotomy with lateral soft tissue release. This was done when the lateral soft tissue contracture was not so severe that passive correction of the hallux valgus deformity was not possible and when the metatarsocuneiform joint was flexible enough to permit additional correction of the first intermetatarsal angle after lateral soft tissue release. The mean patient age was 45.2 (range 23 to 54) years, and the duration of follow-up was 27.5 (range 24 to 46) months. The mean hallux abductus angle decreased from 33.5° ± 3.1° to 11.6° ± 3.3°, and the first intermetatarsal angle decreased from 16.4° ± 2.7° to 9.7° ± 2.1°. The mean American Orthopaedic Foot and Ankle Society hallux-interphalangeal scores increased from 66.6° ± 10.7° to 92.6° ± 9.4° points, and 46 of the 51 patients (90%) were either very satisfied or satisfied with the outcome. No recurrence of deformity or osteonecrosis of the metatarsal head occurred. When lateral soft tissue contracture is not severe and when the metatarsocuneiform joint is flexible enough, distal chevron osteotomy with lateral soft tissue release can be a useful and effective choice for moderate to severe hallux valgus deformity.     

Valgus Ankle Degenerative Arthritis with an Isolated Deltoid Insufficiency and Tibial Varus: A Case Report

We report a case of valgus ankle degenerative arthritis due to chronic isolated deltoid insufficiency combined with tibial varus that was treated successfully with ankle joint preserving surgery. A 63-year-old male complained of right lateral ankle pain with 10 minutes of maximal pain-free walking time. The assessed American Orthopaedic Foot and Ankle ankle-hindfoot scale score was 33 points. The ankle joint showed 18° of valgus deformity with 6° of tibia varus. Medial displacement calcaneal osteotomy, supramalleolar open wedge osteotomy, and deltoid ligament imbrication were performed. At the 2-year follow-up examination, the ankle joint showed 10° of valgus and the tibial plafond showed flattening. The hindfoot showed 7° of valgus. He could run for 2 hours on the treadmill without pain. The American Orthopaedic Foot and Ankle ankle-hindfoot scale score was 90 points. In conclusion, valgus ankle degenerative arthritis with isolated deltoid insufficiency and tibial varus could be treated successfully with realignment using a double osteotomy and additional deltoid imbrication.     

Tibial and talar trabecular lines in the assessment of ankle alignment

The measurement of talar alignment in patients with ankle destruction due to arthritis or previous surgery can be difficult when planning surgery. Radiographs were used to determine whether tibial and talar trabecular lianes are a reliable method of assessment.Trabecular orientation within the talus and distal tibia was measured using an electronic goniometer in standard mortise view anteroposterior (AP) ankle radiographs from 25 normal patients. Radiographs of 12 cadaver ankles were taken in AP, and in 15 and 30° of both internal and external rotation and the trabecular orientation similarly measured. Three independent clinicians assessed the radiographs on two separate occasions.In the normal group the mean trabecular angle was 0.5° valgus (95 percentile: 4° varus to 5° valgus). In the cadaver group of mortise AP radiographs the mean trabecular angle was 1.6° valgus (95 percentile: 4° varus to 10° valgus). Positioning cadaver ankles in internal or external rotation had little effect on the mean trabecular angle, but observer variation increased.Normal ankles consistently have a tibio-talar trabecular angle of between 5° varus and 5° valgus on good mortise view AP radiographs. Uncertainty of measurement increased with rotation or plantarflexion of the ankle. These lines can be used to determine the varus/valgus orientation of the talus within the ankle joint, which may be useful when assessing joints destroyed by disease or removed at surgery.     

Correction of hallux valgus deformity with distal soft tissue realignment and proximal metatarsal osteotomy

Abstract Fifty moderate to severe hallux valgus deformities were corrected with a distal soft tissue realignment and proximal crescentic metatarsal osteotomy. With an average follow-up of 5.6 years, 40 feet (80%) were pain free and 42 (84%) caused no functional limitation. The average hallux valgus angle improved from 38.2° preoperatively to 12.4° at follow-up. The average intermetatarsal angle improved from 15.4° to 6.8°. The arch of motion of the first metatarsophalangeal joint was 75° preoperatively and 62° at follow-up. According to the AOFAS scoring system, 29 results (58%) were excellent, 14 (28%) good, 2 (4%) fair and 5 (10%) poor. The 5 poor results were attributed to recurrence of hallux valgus (2 cases), stiffness (1), hallux varus (1) and malunion of the osteotomy in dorsiflexion (1). The incidences of hallux varus and malunion in dorsiflexion were 8% and 14%, respectively. This technique is valuable in correction of moderate to severe hallux valgus deformities.     

Eccentric ankle arthritis in the sagittal plane: a novel description of anterior and posterior ankle arthritis

BackgroundTo report radiographic characteristics of anterior and posterior ankle arthritis, which demonstrates the eccentric narrowing of either aspect of the tibiotalar joint in the sagittal plane.MethodsRadiographic analysis of 19 ankles with anterior arthritis and 16 ankles with posterior arthritis was performed, which were defined as having both (1) eccentric narrowing of the anterior or posterior tibiotalar joint space on lateral radiographs and (2) talar tilt angle less than 4 degrees on anteroposterior radiographs. Measured radiographic parameters were: Talar tilt angle, medial distal tibial angle (MDTA), talar center migration (TCM), anterior distal tibial angle (ADTA), tibial axis-to-talus ratio (TT ratio), talo-first metatarsal (Meary) angle, hindfoot alignment angle (HAA), hindfoot moment arm, and mechanical axis deviation (MAD). An Intergroup comparison analysis, including a normal control group, was also performed.ResultsThe TT ratio was significantly different between each group, indicating a distinct talus position in the sagittal plane. The anterior group had a significantly larger TCM than the control group and lower ADTA compared to other groups, indicating medial translation of the talus and anterior opening of the tibial plafond. The posterior group demonstrated a significantly higher Meary angle and lower HAA compared to other groups and lower MDTA compared to the control group, indicating lower medial longitudinal arch, valgus heel alignment, and varus tibial plafond. The MAD was significantly higher in both the anterior and posterior groups than the control group, indicating varus lower limb alignment.ConclusionAnterior ankle arthritis demonstrated anteromedial translation of the talus and anterior opening of the tibial plafond. Posterior ankle arthritis was associated with the lower medial longitudinal arch and hindfoot valgus, indicating an association with flatfoot deformity. Both anterior and posterior ankle arthritis were associated with varus lower limb alignment.     

Lower limb alignment in patients with primary valgus ankle arthritis: A comparative analysis with patients with varus ankle arthritis and healthy controls

BackgroundWhile it is commonly acknowledged that the combined effect of lower limb orientation and ankle and hindfoot alignment play a fundamental role in ankle arthritis, supramalleolar/lower limb alignment has received less attention in valgus ankle arthritis. The purpose of this study was to analyze the lower limb alignment of patients with valgus ankle arthritis with primary origin, compared to that of varus ankle arthritis and normal controls. We hypothesized that patients with valgus ankle arthritis would have the opposite pattern of lower limb alignment as those with varus ankle arthritis.MethodsA retrospective radiographic analysis was performed on 61 patients (62 ankles, mean age, 59.3 ± 12 years) with primary valgus ankle arthritis. On preoperative radiographs, seven parameters, including talar tilt angle, medial distal tibial angle (MDTA), talar center migration, anterior distal tibial angle, talo-first metatarsal (Meary's) angle, hindfoot moment arm (HMA), and mechanical axis deviation (MAD), were measured and compared to those of primary varus ankle arthritis (n = 55; mean age, 59.7 ± 8.1 years) and control patients (n = 59; mean age, 29.3 ± 7.3 years).ResultsThe valgus group had a significantly lower mean MDTA than the control group (p < 0.0001), indicating a varus distal tibial plafond in comparison to the control group. Meary's angle and HMA were significantly lower in the valgus group compared to the varus group (p < 0.05 and p < 0.0001, respectively), indicating a lower medial longitudinal arch and valgus hindfoot alignment. On whole limb radiographs, the valgus group showed a greater MAD than the control group, indicating varus lower limb alignment (p < 0.05). However, the MAD did not differ significantly between the valgus and varus groups (p = 0.7031).ConclusionOur findings indicate that a significant proportion of ankles with primary valgus arthritis have a varus tibial plafond and a varus lower limb mechanical axis. This study contributes to our understanding of primary valgus ankle arthritis and suggests that lower limb alignment should be analyzed and considered throughout valgus ankle arthritis realignment procedures.     

Cotton Osteotomy in Flatfoot Reconstruction: A Review of Consecutive Cases

The Cotton osteotomy or opening wedge medial cuneiform osteotomy is a useful adjunctive flatfoot reconstructive procedure that is commonly performed; however, the outcomes are rarely reported owing to the adjunctive nature of the procedure. The Cotton procedure is relatively quick to perform and effectively corrects forefoot varus deformity after rearfoot fusion or osteotomy to achieve a rectus forefoot to rearfoot relationship. Proper patient selection is critical because the preoperative findings of medial column joint instability, concomitant hallux valgus deformity, or degenerative joint disease of the medial column might be better treated by arthrodesis of the naviculocuneiform or first tarsometatarsal joints. Procedure indications also include elevatus of the first ray, which can be a primary deformity in hallux limitus or an iatrogenic deformity after base wedge osteotomy for hallux valgus. We undertook an institutional review board-approved retrospective review of 32 consecutive patients (37 feet) who had undergone Cotton osteotomy as a part of flatfoot reconstruction. All but 1 case (2.7%) had radiographic evidence of graft incorporation at 10 weeks. No patient experienced graft shifting. Three complications (8.1%) were identified, including 2 cases with neuritis (5.4%) and 1 case of delayed union (2.7%) that healed with a bone stimulator at 6 months postoperatively. Meary's angle improved an average of 17.75°, from ?17.24°± 8.00° to 0.51°± 3.81°, and this change was statistically significant (p < .01). The present retrospective series highlights our experience with the use of the Cotton osteotomy as an adjunctive procedure in flatfoot reconstructive surgery.     

Basal medial opening wedge first metatarsal osteotomy stabilized with a low profile wedge plate

Twenty patients underwent 25 basal medial opening wedge osteotomies of the first metatarsal stabilized using a low-profile wedge plate in combination with a distal soft tissue release, distal metatarsal osteotomy and Akin osteotomy as required for correction of a hallux valgus deformity. The mean clinical and radiographic follow-up was 12.2 months. Pre- and post operative radiographs available in 15 cases showed that the median hallux valgus angle (HVA), intermetatarsal angle (IMA) and distal metatarsal articular angle (DMAA) were corrected from 45.5 to 13.1, 17.7 to 9.2 and 243 to 10.0 degrees respectively (p < 0.001). Final radiographic assessment for the whole series showed a median final HVA and IMA of 14.1 and 9.1 respectively. Radiographic union was noted in all but one case which was asymptomatic. One wound infection was treated with oral antibiotics, one hallux varus deformity required soft tissue reconstruction and there was one recurrence. The outcome was reported as good or satisfactory by the patients for 20 of 25 feet. Three patients reported stiffness in the first MTP joint, which improved with joint injection and manipulation. Two plates were removed for prominence. The basal medial opening wedge osteotomy stabilized with a low profile wedge plate was an effective addition for correcting a moderate to severe hallux valgus deformity as part of a double or triple first ray osteotomy.     

Basal osteotomy with lateral soft tissue release and medial plication in the correction of moderate to severe hallux valgus

Moderate and severe hallux valgus usually consists of metatarsus varus and incongruency of the joints. Basal osteotomy and distal soft tissue release provides adequate correction of intermetatarsal angle (IMA) and joint alignment.This is a retrospective study of 26 feet in 20 patients. American Orthopaedics Foot and Ankle Society Score (AOFAS) and subjective grading system for patient's satisfaction were used for assessment. The surgical technique consisted of crescentic basal osteotomy, lateral distal soft tissue release and medial capsular plication according to Roger Mann. Fourteen osteotomies were fixed with K wires and Barouk Screws were used in 12 feet. Patients were mobilised in high heeled shoe post-operatively.Average age was 55.2 years and average follow-up was 25.8 months. The average preoperative hallux valgus angle (HVA) and IMA were 37.38 and 17.27°, respectively. The average post-operative HVA and IMA were 13.3 and 6.4°, respectively. All incongruent joints became congruent after surgery. Sesamoid position improved in 25 feet. Average AOFAS score was 88.8. Ninety-four percent patients were highly satisfied.Complications included breakage of K wire in one leading to change in practice, decreased sensations over medial side of toe in three and mild metatarsalgia in one foot.Basal osteotomy with distal soft tissue release provides good correction of moderate to severe deformity and has high patient satisfaction. Barouk screw provides stable fixation.     

Benefit of Adding Fibular Osteotomy to Open-Wedge,Valgus, Distal Tibial Osteotomy for Correcting Varus Ankle Arthritis: An In Vitro Study

Early-stage varus ankle arthritis can usually be treated with a medial, open-wedge, valgus, distal tibial osteotomy; however, the value of adding a fibular osteotomy has been debated. We sought to determine the increase in the maximum medial osteotomy gap and correction angle provided by fibular osteotomy. In 3 sequential experiments on 12 fresh cadaveric legs, we first performed a medial open-wedge, valgus, distal tibial osteotomy alone. Second, we added a transverse fibular osteotomy. Finally, we added a blocked fibular osteotomy. In each experiment, we measured the maximum corrected osteotomy gap and the maximum correction angle. Correction was defined as the absence of lateral cortex diastasis and talocrural joint incongruity. The mean ± standard deviation maximum osteotomy gaps and correction angles were 8.40 ± 1.6 mm and 10.70° ± 3.3° for the tibial osteotomy alone, 15.70 ± 4.6 mm and 20.20° ± 5.6° for the tibial plus transverse fibular osteotomy, and 16.67 ± 3.7 mm and 20.56° ± 4.6° for the tibial plus transverse plus blocked fibular osteotomies, respectively. The corresponding median maximum correction angles were 10° (range 8° to 18°), 19.5° (range 14° to 30°), and 20° (range 14° to 28°). The osteotomy gap and correction angle in the distal tibial and transverse fibular osteotomy were significantly greater than those in the distal tibial osteotomy alone (p < .001 for both) but not in the distal tibial and blocked fibular osteotomy (p = .62 for the gap and p = .88 for the correction angle). Our data support the clinical use of adjunct transverse fibular osteotomies. The blocked fibular osteotomy provided no additional benefit.     

Ankle valgus and clubfeet.

Congenital equinovarus is a complex deformity that involves the ankle as well as the foot. Although equinus is the obvious and presenting ankle deformity that is typically addressed with serial manipulation, casts, and surgery, ankle valgus is a more insidious and often overlooked problem that evolves with growth. With a high prevalence (67% in this series), it may, in some cases, ameliorate the effects of residual hindfoot varus. More commonly, it may result in prominence of the medial malleolus, lateral shift of the ground reactive forces, compression of the lateral portion of the distal tibial epiphysis, fibular impingement, and excessive shoe wear. If mistaken for hindfoot valgus ("overcorrected clubfoot"), inappropriate hindfoot surgery may result. Although one may temporize with orthoses, definitive treatment options include medial malleolar epiphysiodesis or, in mature patients, supramalleolar osteotomy. We recommend a weight-bearing anteroposterior radiograph of the ankles in any patient presenting with valgus and suspected of having overcorrected congenital equinovarus, particularly if surgical intervention is being contemplated. If valgus deformity is noted in the ankle, hindfoot surgery may be contraindicated.     

高弓马蹄内翻足术后复发与跟骨截骨

目的 探讨高弓内翻足手术治疗后的内翻复发,跟骨截骨外移的矫正度与内翻复发的关系.方法 23例(31足)成人高弓内翻足患者,年龄13～59岁,平均36岁.以术前Coleman试验可否矫正、经内侧软组织和(或)肌腱松解后后足内翻被动矫正情况以及是否行跟骨截骨,将患足分为4组.并以被动可矫正至中立位和外翻5°以上为两个界限.进行统计.跟骨截骨可以为跟骨轴位水平方向上的截骨外移,截骨外移后的欠状面上的上移,以及跟骨的楔形闭合截骨.结果 内翻复发9足,5°以下5足,5°以上4足,平均4.23°±2.15°.末行跟骨截骨12足中,术前Coleman试验可矫正至中立位3足均复发,术前Coleman试验可矫正至外翻5°以上的4足均未复发.术前Coleman试验不町矫正,术中经软组织松解后可矫正至中立位的2足,术后均复发;术前Coleman试验不可矫正,术中可矫正至外翻5°以上的3足,内翻复发1足.行跟骨外移截骨19足中,术前Coleman试验可矫正至中立位9足,1足内翻复发;术前Coleman试验不可矫正,术中可矫正至中立位的7足,术后2足复发;术前Coleman试验不可矫正,术中可矫正至外翻5°以上者3足,无内翻复发.结论 Coleman试验能否矫正后足的内翻,并非是否行跟骨外移截骨术的依据;而被动手法矫正是判断是否行跟骨截骨的关键,外翻5°是一个重要的指标.     

Supramalleolar Osteotomy With Distraction Arthroplasty in Treatment of Varus Ankle Osteoarthritis With Large Talar Tilt Angle: A Case Report and Literature Review

We treated a 57-year-old female with modified Takakura stage 3B varus ankle osteoarthritis. Her preoperative talar tilt angle was 21.3°. The patient wished to avoid ankle joint arthrodesis or replacement. Therefore, medial opening wedge supramalleolar osteotomy with fibular osteotomy was used for her varus ankle osteoarthritis. Also, fixed medial distraction arthroplasty was performed to improve her talar tilt. After 3 months, the external device was removed, and the patient was allowed partial weightbearing and began full weightbearing 4 months postoperatively after the osteotomy site had reached bony union radiographically. At the 3-year follow-up visit, a radiograph showed the medial ankle joint space enlargement had been maintained. The talar tilt angle had decreased to 3.3°, and the modified Takakura stage had improved to stage 1. The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale score had improved from 26 points preoperatively to 85 points at 3 years postoperatively. Our findings suggested that good clinical and radiologic results can be achieved with supramalleolar osteotomy combined with distraction arthroplasty in the treatment of varus ankle osteoarthritis with a large talar tilt angle.     

Results of step-cut medial malleolar osteotomy

BACKGROUND: Treatment of certain complex ankle pathology, such as a talar body fracture or osteochondral lesion requiring grafting, can necessitate medial malleolar osteotomy for adequate operative exposure. This paper evaluates the step-cut medial malleolar osteotomy for exposure of the ankle joint. METHOD: Fourteen patients with intra-articular pathology, including talar body fractures or osteochondral lesions necessitating extensive intra-articular exposure had step-cut malleolar osteotomy. The average age of the patients was 37 (range 20-90) years, and the average followup was 8 months. RESULTS: All 14 patients had an uncomplicated intraoperative course, with excellent exposure of the ankle joint. All patients had prompt healing of the osteotomy by 6 weeks after surgery without loss of reduction. None of the patients had pain at the osteotomy site. CONCLUSIONS: Step-cut medial malleolar osteotomy is an excellent, reproducible method for extensive exposure of the talar dome.     

Sprunggelenkprothese bei Valgusarthrose

Ankle osteoarthritis (OA) is often associated with deformities. Valgus OA is less frequent than varus OA and causes of valgus OA include medial ligament instability, flat foot and posttraumatic situations, e.g. fractures of the fibula or lateral tibial plafond. The importance of the mechanical axis is generally accepted in orthopedic surgery. In cases of implantation of total ankle replacements the normal biomechanics need to be restored in order to have a correct and pain-free functioning total ankle replacement both in the short and long-term. The two most important criteria are (1) an anterior tibio-talar angle of about 90° and (2) a neutral hindfoot position. The hindfoot position is measured with the hindfoot alignment view according to Saltzman. In this view, healthy feet are in neutral or minimal varus position of 1?C2° and not in a valgus position as generally assumed. The following operative steps are performed depending on the degree and localization of the valgus deformity: (1) total ankle replacement, (2) supramalleolar or (3) inframalleolar osteotomy/arthrodesis, (4) medial ligament repair, (5) fibula osteotomy and (6) syndesmotic reconstruction.     

Effect of Total Knee Arthroplasty on Coronal Alignment of the Ankle Joint

BackgroundThe effect of total knee arthroplasty (TKA) on the ankle joint is not entirely clear. The purpose of this study is to assess postoperative changes in the coronal alignment of the ankle joint in patients undergoing TKA for various degrees of knee deformity.MethodsThis retrospective study included 107 patients who had undergone TKA for primary osteoarthritis. In all cases, preoperative coronal alignment deformity of the knee was corrected in an attempt to restore the native mechanical axis of the knee. Patients were stratified into 3 groups according to the degree of knee coronal alignment correction achieved intraoperatively: group 1 (<10° varus/valgus correction, n = 60), group 2 (≥10° varus correction, n = 30), and group 3 (≥10° valgus correction, n = 17). Knee/ankle alignment angles were measured on full-length, standing anteroposterior imaging preoperatively and postoperatively and included the following: hip-knee-ankle angle, tibial plafond inclination (TPI), talar inclination (TI), and tibiotalar tilt angle.ResultsSignificant changes in ankle alignment, specifically with regard to TPI (9.5° ± 6.9°, P < .01) and TI (8.8° ± 8.8°, P = .03) were noted in the ≥10° valgus correction group compared to the other 2 groups. Regardless of the degree of knee deformity correction, TKA did not lead to significant changes in the tibiotalar tilt angle.ConclusionA correction of ≥10° in a genu valgum deformity can affect ankle joint alignment, leading to alterations in TPI and TI. These findings need to be taken into consideration in assessing candidates for TKA as a possible cause of postoperative ankle pain.