SLR - December 2021 - Andrea C. Batra
Reference: Lim JW, Eom JS, Kang SJ, Lee DO, Kang HJ, Jung HG. The Effect of Supramalleolar Osteotomy without Marrow Stimulation for Medial Ankle Osteoarthritis: Second-Look Arthroscopic Evaluation of 29 Ankles. J Bone Joint Surg Am. 2021 Oct 6;103(19):1844-1851. doi: 10.2106/JBJS.20.00502. PMID: 34138774.Level of Evidence: Level IV
Scientific Literature Review
Reviewed By: Andrea C. Batra, DPM
Residency Program: Highlands/Presbyterian St. Luke’s Medical Center – Denver, CO
Podiatric Relevance: Joint salvage and cartilage preservation treatments for unicompartmental ankle arthritis are widely debated topics particularly for younger patients with intermediate-stage arthritis. This article discusses how to use a supramalleolar osteotomy (SMO) to realign the ankle mortise and effectively allow for redistribution of load-bearing and tissue regeneration without the use of an adjunct bone marrow stimulation. The authors hypothesized that SMO without a bone marrow stimulating procedure for the treatment of medial compartment ankle arthritis would show favorable clinical and radiographic outcomes and that tissue might regenerate over the denuded ankle joint.
Methods: Data from patients who underwent SMO for medial compartment ankle arthritis from August 2007 – April 2018 was reviewed. Twenty-nine patients were included in the final analysis. The average age of patients was 58.2 years-old and the majority of ankles (21/29, 72.4 percent) were classified as Takakura stage IIIa. The SMOs were all performed by the senior author via a medial opening-wedge osteotomy with tricortical iliac allograft. Second-look arthroscopy was performed after osseous union of the SMO and removal of hardware. Patients were evaluated preoperatively, at six months, at one year, and annually thereafter via the visual analog scale (VAS), the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot functional score, ankle range of motion, and patient satisfaction.
Results: Mean duration of follow-up was 35.3 months and osseous union of SMO sites was achieved in all patients. The mean VAS and AOFAS scores improved from 6.2 and 60.5 preoperatively to 1.5 and 88.3 postoperatively respectively. The mean ankle range of motion (dorsiflexion/plantarflexion) improved from 14.8 degrees/36.0 degrees to 17.4 degrees/40.0 degrees postoperatively and a total of 93.1 percent of patients (27/29) classified themselves as very satisfied or satisfied with the procedure. On second-look arthroscopy, 26 ankles (89.7 percent) showed tissue with a cartilaginous appearance in the previously denuded talar dome or tibial plafond, and 16 ankles (55.2 percent) showed regeneration in both the tibial plafond and the talar dome.
Conclusions: The authors concluded that this showed that SMO without a bone marrow-stimulating procedure allowed for regeneration of cartilage-appearing tissue in most ankles (89.7 percent). They also noted that this procedure had a high patient satisfaction rate (93.1 percent) and favorable clinical outcomes. Given the debates surrounding indications for total ankle arthroplasty and the optimal treatment of cartilage pathology it is worthwhile to consider alternative joint-sparing procedures that improve the alignment of the ankle mortise. A SMO could be considered in a patient with medial compartment ankle arthritis to rebalance the ankle joint and improve patient functionality in the short-term without compromising the ability to perform joint destructive procedures in the future.