SLR - July 2016 - Timothy Miller

Supramalleolar Osteotomy With or Without Fibular Osteotomy for Varus Ankle Arthritis

Reference: Hongmou Z, Xiaojun L, Yi L, Hongliang L, Junhu W, Cheng L. Supramalleolar Osteotomy With or Without Fibular Osteotomy for Varus Ankle Arthritis. Foot Ankle Int. 2016 May 17.

Scientific Literature Review

Reviewed By: Timothy Miller, DPM
Residency Program: Morristown Medical Center

Podiatric Relevance: Ankle pain is a common presenting symptom in patients. Some patients may have clinical and radiographic evidence of osteoarthritis due to a varus deformity. More than half of the tibiotalar joint surface is usually preserved in early and midstage ankle osteoarthritis. Due to this, treatment is challenging and leads to some controversy. The purpose of a supramalleolar osteotomy is to realign the weightbearing surface of the ankle joint, restore the congruence of the tibiotalar joint surface, normalize biomechanic forces and postpone progression of osteoarthritis by reducing contact pressure on the medial part of tibiotalar joint. Some authors suggest that a fibular osteotomy should be performed, while others state that the fibula must be preserved. The hypothesis of the study is that the fibular osteotomy may restore the alignment and help in the congruency of the joint. The purpose of the study was to retrospectively analyze the clinical and radiologic outcomes of supramalleolar osteotomy for the treatment of varus ankle arthritis comparing those with and without fibular osteotomy.

Methods: The Takakura classification for ankle arthritis was used to radiographically evaluate the ankle varus deformity. Forty-one Takakura stage 2 and 3 varus ankle osteoarthritis patients treated with supramalleolar osteotomy were included. Fourteen males and 27 females with a mean age of 50.7 (range, 32–71) years were followed with a mean of 36.6 (range, 17–61) months. There were 22 cases with fibular osteotomy and 19 without. The American Orthopedic Foot and Ankle Society (AOFAS) ankle hindfoot score, Maryland foot score and Ankle Osteoarthritis Score (AOS) were used for pre- and postoperative functional evaluation. The tibial articular surface angle (TAS), talar tilt (TT), tibiocrural angle (TC) and tibial lateral surface angle (TLS) were evaluated pre- and postoperatively.

Results: At the last follow-up, the mean AOFAS score (from 50.8 to 83.1 points) and Maryland score (form 58.3 to 81.6 points) in overall were improved. The mean AOS pain (42.6 to 26.1 points) and function (from 53.4 to 36.8 points) scores were decreased. For radiologic evaluation, all the included parameters were improved (P < .05) except TLS. The mean Takakura stage was decreased. No significant difference could be detected in comparing the functional outcomes between those with and without fibular osteotomy. However, in the fibular osteotomy group, talar tilt was decreased and tibiocrural was improved significantly.

Conclusions: Supramalleolar osteotomy with fibular osteotomy may be necessary in cases with large talar tilt and small tibiocrural angles. Supramalleolar osteotomy led to substantial functional improvement and malalignment correction for varus ankle arthritis. The functional outcome of the SMOT was good in terms of pain relief and correction of malalignment. The radiographic evaluation showed reduction in signs of ankle arthritis. Joint-preserving treatment of ankle arthritis should slow progression of arthritis, leading to improvement of function and pain. Uneven pressure on articular surfaces of lower extremities leads to degeneration. This may induce arthritis. Realignment osteotomy will help delay the progression of arthritis. 

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