SLR - October 2014 - Francesca Zappasodi

Supramalleolar Osteotomy: Techniques, Indications, and Outcomes in a Series of 83 Cases

Reference: Colin F, Gaudot F, Odri G, Judet T. Supramalleolar Osteotomy: Techniques, Indications, and Outcomes in a Series of 83 Cases. Ortho Traumatol Surg Res. 2014 Jun; 100(4): 413-8.

Scientific Literature Review

Reviewed By: Francesca Zappasodi, DPM
Residency Program: Florida Hospital East Orlando

Podiatric Relevance: This retrospective study was designed to evaluate the clinical and radiographical results of supramalleolar osteotomies performed in patients with tibiotalar arthritis and concomitant hind foot alignment deformities. An additional goal of this study was to identify prognostic factors to indicate when a supramalleolar osteotomy is recommended. 

Methods: This level four retrospective study was performed in the orthopedic surgery unit of the Raymond Paincare Hospital in France. To be included in the study, patients required post-traumatic and symptomatic ankle arthritis with a coronal plane deformity. Patients with neurological diseases, rheumatological diseases, infections, previous midtalar arthrodesis, or previous subtalar arthrodesis were excluded from the study. Eighty-three patients, 59 men and 24 women, had supramalleolar osteotomies performed between 1988-2011. The mean age at the time of surgery was 45. There were 62 patients with ankle varus deformities and 21 with ankle valgus deformities. At the pre-operative visit and final follow-up visit, clinical and radiological assessments were performed. AOFAS ankle-hindfoot scale was used to assess patients clinically. Patients were also questioned if their pain was relieved with walking on an inclined sidewalk slanted in the opposite direction of their deformity. If patients responded yes, they were deemed to have a positive “sidewalk” sign. AP, lateral, mortise, and Meary view weightbearing radiographs were taken and analyzed by an independent observer. The degree of ankle deformity was quantified with the Digan and Annonier method. Additional angles that were measured included: the Tibial Articular Inferior Surface (TAS) angle, the Tibial Lateral Surface (TLS) angle, and the Talar Tilt (TT) angle. Based on these angular measurements, patients received corrective or palliative osteotomies for extra-articular or intraarticular deformities, respectively. Of the 62 varus deformities, 41 patients had a lateral closing wedge osteotomy and 21 had a medial opening wedge osteotomy. Of the 21 valgus deformities, 12 patients underwent a medial closing wedge osteotomy and nine underwent a lateral opening wedge osteotomy. Additional procedures performed included percutaneous tendoachilles lengthening in five cases, subtalar arthrolysis in two cases, and forefoot procedures in three cases. Postoperatively, patients were placed in below knee plaster casts after surgery, for six weeks duration.

Results: Radiological union of the supramalleolar osteotomies occurred after a mean of 11 weeks with no significant difference in time to union among the different osteotomies performed. In the varus group, AOFAS scores improved significantly from 58 to 73 (p<0.001). The Meary angle improved from 13 degrees varus to 1 degree valgus and patients had significant correction of the TAS and TT angles (p<0.001). The valgus group also had a significant improvement in AOFAS scores that increased from 66 to 80 (p<0.001). In addition, the Meary angle improved from 17 degrees valgus to 8 degrees valgus. There was also significant correction of the TAS angle. AOFAS scores above 65 and patients with a positive “sidewalk” sign showed a significant correlation. Postoperatively, some of the complications included: overcorrection, septic non-union, scar dehiscence, and impingment. There were no vascular or neurological complications observed.

Conclusions: Supramalleolar osteotomies are a reproducible surgical technique to obtain re-alignment of coronal plane deformities in cases of post-traumatic tibiotalar arthritis.  Realignment of the ankle joint and subsequently realignment of the mechanical load can relieve stress on the degenerative joint. A positive sidewalk sign can be predictive of good results of this corrective osteotomy in patients.

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