2018 Ankle SMO Pilon Fx. - OhtoMedical

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Surgical Technique Guide

2018 Ankle SMO & Pilon Fx.

Introduction

3OhtoFix® for Supra Malleolar Osteotomy Technique Guide

Table of Contents ●●●

감수 : 김학준 교수, 이영구 교수, 이모세 교수

Introduction Characteristic Features / Principle of SMO

Keys to Success in SMO

Distal pilon Fx. or ankle Fx.의 사용법

Indications and Contraindications

Clinical Results

Surgical Techniques Preoperation and Approach / Incision

Positioning and Fixation of the plate

Lateral hinge fracture가 발생한 경우

Bone graft / Fibular Osteotomy

OhtoFix SMO Informations

Product Information

Articles in Medical Jounals

Indications for Supramalleolar Osteotomy in Patientswith Ankle Osteoarthritis and Varus Deformity

Supramalleolar Osteotomy With Bone Marrow Stimulation for Varus Ankle Osteoarthritis

Effect of Combined Fibular Osteotomy on the Pressure of the Tibiotalar and Talofibular Joints in Supramalleolar Osteotomy of the Ankle: A Cadaveric Study

Safe Zone for Medial Open-Wedge Supramalleolar Osteotomy of the Ankle: A Cadaveric Study

Supramalleolar Osteotomy With or Without Fibular Osteotomy forVarus Ankle Arthritis

A Cohort Study of Patients Undergoing Distal Tibial Osteotomy without Fibular Osteotomy for Medial Ankle Arthritis with Mortise Widening

Low tibial osteotomy for varus-type osteoarthritis of the ankle

4

Characteristic Features of SMO

Rigid with Locking Compression

Rigid with Locking Compression

Short

Short

Anatomical

Anatomical

Introduction


Characteristic Features of Pilon Fx.

● Joint preserving surgery● Shift weight bearing line from medial to lateral compartment

1. Proper patient selection

2. Proper preparative planning

3. Precise surgical technique

SMO plate 는 opening gap 8mm 를 기준으로 만들었으므로

골절의 정복에 사용할때는 3~5도를 bending 해서

사용해야 합니다.

Principle of SMO

Keys to Success in SMO

SMO Bending 방법

6

SMO Kim HJ

Clinical Results

Study No. F/U Clinical Score

Takakura JBJS br(1995) 18 6.11 yr Fair → Excellent

Tanaka JBJS br(2006) 25 8.3 yr Fair→ Good

Lee JBJS am(2011) 16 2.3 yr Fair→ Excellent

Ahn & Lee JBJS am (2015) 18 3.2 yr Fair → Good

Hongmou Z FAI (2016) 41 4.6 yr Bad → Good

- Lee WC, Moon JS, Lee K, Byun WJ, Lee SH. Indications for supramalleolar osteotomy in patients with ankle osteoarthritis and varus deformity. J Bone Joint Surg Am. 2011;93:1243-8.

- Choi JY, Suh JS. Low tibial osteotomy. J Korean Foot Ankle Soc. 2014;18(4):141-146.

- Takakura Y, Tanaka Y, Kumai T, Tamai S. Low tibial osteotomy for osteoarthritis of the ankle. Results of a new operation in 18 patients. J Bone Joint Surg Br. 1995;77:50-4.

- Tanaka Y, Takakura Y, Hayashi K, Taniguchi A, Kumai T, Sugimoto K. Low tibial osteotomy for varus-type osteoarthritis of the ankle. J Bone Joint Surg Br. 2006;88:909-13.

- Lee WC, Moon JS, Lee K, Byun WJ, Lee SH. Indications for supramalleolar osteotomy in patients with ankle osteoarthritis and varus deformity. J Bone Joint Surg Am. 2011;93:1243-8.

- Ahn TK, Yi Y, Cho MJ, Lee WC. A cohort study of patients undergoing distal tiial osteotomy without fibular osteotomy for medial ankle arthritis with mortise widening. J Bone Joint Surg Am. 2015;97:3861-8.

- 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;37;1001-7.

Indications and Contraindications

Indications● Age ≤ 70● Medial OA with Varus deformity (Takakura-Tanaka 2 ~ 3b)● Medial OCD of talus● Ankle joint ROM preserved● Varus tilt angle > 0°

Contraindications● Lateral OA● Limited joint ROM● Neuropathic disorders (Charcot foot)● Inflammatory arthritis (rheumatic arthritis, autoimmune disease)

Introduction


1. Preoperative Planning● Supramalleolar osteotomy은 관절의 이상 정렬에 대하여

정확하게 평가하는 것이 무엇보다도 중요합니다.

이를 위해 체중 부하 상태에서 전후면(AP) 및 측면(lateral) 방사선

사진을 촬영하여 전후면 사진에서 경골의 축 및 원위 경골 관절면

이 이루는 각도(tibial anterior surface angle, TAS)

거골의 내반경사(Varus tilt angle, VTA) 및 측면상에서 같은 선이

이루는 각도(tibial lateral surface angle, TLS)를 측정하는 것이

필요합니다. 정상인에서 평균 TAS각도는 각각 93.3°, 88.1°로

확인되었으며, TLS 각도는 81.0°로 보고한바 있습니다.

● 절골술을 시행할 때 목표는 반대측과 비교하여 TAS 및 TLS를

정상 수치 이내로 교정하는 것이 합리적이겠지만 약간 ‘과교정’을

하는 것이 적절한 치료 방법입니다.

진행된 관절염에 있어서 저교정을 하는 것보다

과교정을 하는 것이 더 좋은 결과를 가져온다는 데는

큰 이견은 없으나 어느 정도 과교정을 시행할 것인가에 대해서는

많은 의견차이를 보이고 있습니다.

● 지나친 과교정은 외측 비골 하 동통을 유발할 수 있어

TAS는 95°를 목표로 하고, TLS의 경우 과교정 시에

거골 경부(talar neck)의 골극이나 원위경골의 골극을

충분히 제거하고 시행하도록 권고되지만 족배 굴곡(dorsal flexion)

의 제한이 초래될 수 있어 81~82°를 목표로 교정할 것을

제안하고 있습니다.

Preoperation and Approach

- Lee WC, Moon JS, Lee K, Byun WJ, Lee SH. Indications for supramalleolarosteotomy in patients with ankle osteoarthritis andvarus deformity. J Bone Joint Surg Am. 2011;93:1243-8.

- Oh HK, Suh JS. Tibial axis-talar ratio measured on standing ankle lateral radiographs. J Korean Foot Ankle Soc. 2006;10:140-3.

- Tanaka Y, Takakura Y, Hayashi K, Taniguchi A, Kumai T, Sugimoto K. Low tibial osteotomy for varus-type osteoarthritis ofthe ankle. J Bone Joint Surg Br. 2006;88:909-13.


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2. Ankle Arthroscopy● 관절경(arthroscopy) 검사를 하는 목적은 연골 손상 정도를

판단하기 위함입니다. 관절경시행시에는 활액막 절제술을

시행하고 내측 삼각인대(deltoid ligament) 유리술을 시행하여

내측 관절면의 압력을 줄여줍니다.

또한 관절연골의 손상정도에 따라 손상정도가 심하지 않으면

정열을 talus의 중심에 두고 연골손상이 심하면 외측으로

이동합니다.

또한 OCD of Talus가 있을 때 fragment가 있으면 제거하고

아무것도 안할수도 있고, 또한 microfracture를 시행할 수도

있으며, 혹은 Mosaicplasty, ACI, Stem cell 등을

이식해 넣을 수도 있습니다.

그러나 이러한 것 좁은 공간에서 수술을 하면 iatrogenic injury를

더 줄수 있습니다. 연골에 잘 덮혀있어 stable하면

수술적 치료를 하지 않고 SMO만을 시행합니다.

3. C-arm method● 절골술 후 C-arm을 통해 교정된 정열이 talus의 중심에서

외측으로 이동했는지 확인합니다.


Surgical Techniques

- Moon JS, Shim JC, Suh JS, Lee WC. Radiographic predictability of cartilage damage in medial ankle osteoarthritis. Clin Orthop Relat Res. 2010;468:2188-97.

- Lee WC, Kim JR. Supramalleolar osteotomy in patients with varus ankle osteoarthritis. J Korean Foot Ankle Soc. 2011;15:119-123.

1. Approach - Incision● 피부절개는 계획된 절골술의 높이의 전방으로 종절개

(longitudinal incision)를 가하는데, 이는 수술 후 창상 문제가

발생하더라도 금속판의 직접 노출을 피하기 위해서입니다.

또한 삼각인대 유리술(deltoid ligament release)이나

골극 절제와 같은 부가 수술이 필요한 경우가 많으므로

피부 절개를 족관절 내과 앞으로 연장 할 수도 있습니다.

2. Osteotomy● 절골술의 위치는 내측 관절면에서 약 5cm 상방이며

경골 절골을 하기 위해 경골의 종절개를 시행합니다.

절골면의 방향과 위치를 결정한 후

retractor 를 앞과 뒤로 골막과 뼈사이에 넣어서 경골 후내측의

posterior. tibial artery 와 tibial nerve를 보호합니다.

● 예상 절골면을 따라 C-arm 촬영 하에 K-강선 두 개를

삽입합니다. 이때 K-강선의 방향은 syndesmosis의 ‘safe zone’

즉 A-B의 proximal part 1/3 부근을 향하도록 합니다.

점선과 같은 방향으로 절골이 이루어 진경우는

lateral hinge Fx.가능성이 높으므로 실선 방향(safe zone)으로

K-강선을 삽입 합니다.

Incision

10

- Becker AS, Myerson MS. The indications and technique of supramalleolar osteotomy. Foot Ankle Clin. 2009;14:549-561.


- Kim YS, Park EH, Koh YG, Lee JW. Supramallolar osteotomy with bone marrow stimulation for varus ankle osteoarthritis. Am J Sports med. 20014;42:1558-1566.

- Nha KW, Lee SH, Rhyu IJ, Kim HJ, S JG, Han JH, Yeo ED, Lee YK. Safe zone for medial open-wedge supramalleolar osteotomy of the ankle: A cadaveric study. Foot Ankle Int. 2016;37;102-8.

SMO Kim HJ

● Oscilliating saw를 이용하여 삽입된 두개의 K-강선 하방에서

절골술을 시작합니다.이 때 외측의 피질골을 보호하여

개방(opening) 시에 지렛대 역할을 하도록 합니다.

● 절골술은 lateral cortex의 약 5mm가량 앞과 뒤가 남을 때까지

충분히 해야 합니다.

3. Three chisel technique

● 첫 번째 chisel을 lateral의 끝부분에서 5mm 위치까지

삽입시킵니다. 두 번째 chisel은 첫 번째 chisel을 따라 삽입시키며

세 번째 chisel을 첫째와 두 번째 사이에 삽입시킵니다.

절골도를 너무 깊게 넣지 않도록 하여 외측 피질골이

골절되지 않도록 주의합니다.

● Alignment가 목표 치에 도달하였다면 gap spreader로

절골면을 열고 metal block을 삽입합니다.

그 후 C-arm을 보고 절골 정열의 정도가 적당한지 판단합니다.

만일 gap이 크면 작은 사이즈로 gap이 작으면 큰 사이즈의

metal block으로 교체 후 다시 C-arm을 보고 확인합니다.

(metal block 은 1mm 단위로 되어 있습니다. bony spreader로

조절하는 것 보다 매우 유용합니다.)


Surgical Techniques



1. Positioning and Fixation of the plate

● C-arm을 이용하여 plate의 위치가 확정되면 metal block과

연결된 작은 screw를 느슨하게 연결하고 끝까지 조이지는

않습니다.

● C- arm 을 보고 금속판의 위치가 적당한지 sliding hole 을 통해

이동시켜 봅니다. 매우 중요합니다.

즉 금속핀이 관절면이나 절골술내에 안들어가게 해야 합니다.

● 검은색 알루미늄의 Aiming guide를 plate의 distal portion 에

연결합니다. 그 후에 가이드 핀을 삽입하여 절골술 위치와

관절면의 관계를 파악합니다.

Positioning and Fixation of the plate

연

12

① ②

③

● Plate의 distal screw 삽입을 위해 aiming guide를 통하여

locking sleeve를 연결합니다.

① 번에 가이드 핀을 임시로 고정한 후 이것을 기준으로

다른 두 sleeve에 있는 3.5 locking screw를 고정합니다.

③ 번 screw를 고정합니다.

견고한 고정력을 얻기 위해 가능한 긴 screw를 사용합니다.

그러나 Far cortex 를 뚫지 않습니다.

①

③


Surgical Techniques

● Lateral hinge Fx. 발생시 가장 좋은 방법으로는 compression

screw로 그림과 같이 압박고정을 하는 것입니다.

절골면의 바로 위에 있는 sliding hole에 4.5mm compression

screw를 삽입하여 고정합니다. (Open HTO 에서도 이 방법을

사용하고 있습니다.)

Lateral hinge Fx.가 없다면 시행하지 않아도 되며,

뼈와 금속판사이가 벌어져 있다면 견고한 고정력을 위해서

약 1~2mm 정도만 compression하여 고정해도 됩니다.

● Distal portion 고정 후 proximal portion의 가장 위에 있는

hole에 drill bit으로 near cortex만 임시로 고정합니다.

(이러한 방법을 사용하면 임시 금속판을 고정시킬수 있고

compression 시에 움직임을 허용할 수 있어 매우 유용합니다.)

● Lateral hinge Fx.의 발생시 다른 대처방법은 가장 아래의

③번 3.5 locking screw를 고정하기 전에 K wire로

distal ankle에서 절골술의 위쪽으로 가이드 핀을 고정하거나,

4.0 cannulated screw를 먼저 고정하여 lateral hinge Fx.가

벌어지지 않게 합니다.

Lateral hinge fracture가 발생한 경우

14

① ②

③

SMO Kim HJ

● 그 후 나머지 hole을

5.0 locking screw로

고정하고 가장 근위부에 있는

hole은 다시 drilling하여

far cortex까지 뚫은 후

고정합니다.

최종 완성된 그림

Positioning and fixation of the plate


Surgical Techniques

Bone graft

뼈이식

● 아직 정확한 이론적인 근거는 없습니다. 빈 공간에 자가뼈를

이식하는 것이 가장 좋으나 골반의 통증이 발생할 수 있습니다.

Open HTO 에서는 12mm gap 까지는 뼈이식을 안해도

잘 자란다는 논문이 있습니다.

그러나 족부에서는 무릎부위보다 soft tissue 가 적어서

뼈이식을 안해도 뼈가 새로이 나오는지는 아직 분명치 않습니다.

16

- Lee JS, Park YJ, Wang L, Chang YS, Shetty GM, Nha KW. Modified Iliac Crest Reconstruction with Bone Cement for Reduction of Donor Site Pain and Morbidity after Open Wedge High Tibial Osteotomy: A Prospective Study. Knee Surg Relat Res. 1;28(4):277-282. 2016

- Han JH, Kim HJ, Song JG, Yang JH, Bhandare NN, Fernandez AR, Park HJ, Nha KW. Is Bone Grafting Necessary in Opening Wedge High Tibial Osteotomy? A Meta-Analysis of Radiological Outcomes. Knee Surg Relat Res. 27(4):207-20. 2015

● 비골 절골술은 발목 내측 관절염이 있는 환자의 과상부 절골술

시에 거골-비골 관절(talofibular joint)의 압력을 줄일 수 있다는

연구결과가 있습니다.

아직 정립된 이론은 없으나 SMO 약 6~7mm 이상하면 족관절면

에 압력이 증가하므로 Fibulectomy를 시행하는 것이 좋습니다.

● 이를 위해 비골의 원위부에 종절개를 가합니다.

절골부위는 syndesmosis의 상단보다 0.5~1.0cm 정도

근위부에서 하게 되므로 그 부분을 중심으로 fibular plate를

부착할 만큼 절개합니다.

피부와 피하지방을 벌린 다음, 절골 위치를 C-arm으로 확인 후

외측 상방에서 내측 하방을 향하도록 narrow oscilliating saw를

이용하여 절골술을 시행합니다.

● 외반된 비골의 각도 교정이 적당하다고 판단되면 금속판을

절골부위의 원위부에서 screw를 삽입하여 고정합니다.

* Fibular plate는 약간 bending이 되어 있습니다.

Fibular Osteotomy(비골 절골술)


- Choi GW, Lee SH, Nha KW, Lee SJ, Kim WH, Uhm CS. Effect of combined fibular osteotomy on the pressure of the tibiotalar and talofibular joints in supramalleolar osteotomy of the ankle: A cadaveric study. J Foot Ankle Surg. 2017;56;59-64.


Surgical Techniques


18

Locking Ankle Osteotomy Plate

Locking Distal Fibular Plate

Sliding hole and metal block

Divided into left and right

Titanium material was produced

Compression hole

Product Information


Model No. T.Length Width Type Hole

31417-43003 82.5mm 15mm R 3H

31417-33003 82.5mm 15mm L 3H

Model No. T.Length Width Type Hole

31418-92904 54mm 10mm St. 4H

Locking Ankle Osteotomy Plate

Locking Distal Fibular Plate

Model No. Size

31502-90203 ~ 31502-91112

3mm~12mm

U-Block

Model No. Size

5.0 Locking cortex Screw

32235-50020 ~ 32235-50080

20mm~50mm (2mm Unit)


3.5 Locking cortex Screw

32223-35010 ~ 32223-35060



5.0 Locking Cannulated Screw

32435-50020 ~ 32435-50080



4.5 Cortical Screw 32103-45020 ~ 32103-45060


Screw


20

Ankle Target Guide R <36101-09002>

Ankle Bone Spreader <36102-09001> Ankle Spreader <36102-09002>

Ankle Osteotome Chisel 10mm, 15mm, 20mm <36103-09001~36103-09003>

Remover Mallet <60-026>

Ankle Target Guide <36101-09001>

Barret Retractor <60-029> Hohmann Retractor <42-061>

Locking Drill Sleeve 3.5 <36203-02035> Locking Drill Sleeve Insert 3.5 <36203-02015>

Locking Drill Sleeve 5.0 <60-017> Locking Drill Sleeve Insert 5.0 <60-017>

U-Block Assemble Driver <60-020> Depth Gauge <47-042>

Product Information


Hex Screw Driver Shaft Tip 2.5 <36210-25108>

Drill Bit 4.3 <16201-43240> Drill Bit 3.2 <16201-32210>

Drill Bit 3.0 <16201-30142> DCP Drill Guide 3.2 <47-076>

Hex Screw Driver Shaft Tip 3.5 <60-018>

Hex Screw Driver 3.5 <47-016> Screw Holding Forceps 5.0 <60-021>

Hex Screw Driver 2.5 <47-015> Screw Holding Forceps 3.5 <60-041>

Torque Limits 4N Driver <61-036> Ankle Plate Bender <36104-09001>

Articles in Medical Jounals

22

Indications for Supramalleolar Osteotomy in Patientswith Ankle Osteoarthritis and Varus DeformityWoo-Chun Lee, MD, Jeong-Seok Moon, MD, Kang Lee, MD, Woo Jin Byun, MD, and Sang Hyeong Lee, MD

Supramalleolar Osteotomy With Bone Marrow Stimulation for Varus Ankle OsteoarthritisYong Sang Kim, MD, Eui Hyun Park, MD, Yong Gon Koh, MD, and Jin Woo Lee, MD, PhD

Effect of Combined Fibular Osteotomy on the Pressure of the Tibiotalar and Talofibular Joints in Supramalleolar Osteotomy of the Ankle: A Cadaveric StudyGi Won Choi, MD, PhD , Soon Hyuck Lee, MD, PhD , Kyung Wook Nha, MD, PhD , Sung Jae Lee, PhD , Won Hyeon Kim, Chang-Sub Uhm, MD, PhD

Safe Zone for Medial Open-Wedge Supramalleolar Osteotomy of the Ankle: A Cadaveric StudyKyung Wook Nha, MD, PhD, Soon Hyuck Lee, MD, PhD, Im Joo Rhyu, MD, PhD, Hak Jun Kim, MD, PhD, Jae Gwang Song, MD, Jae Hwi Han, MD, Eui Dong Yeo, MD, and Young Koo Lee, MD, PhD

Supramalleolar Osteotomy With or Without Fibular Osteotomy for Varus Ankle ArthritisZhao Hongmou, MD, PhD, Liang Xiaojun, MD, Li Yi, MD, PhD, Liu Hongliang, MD, Wang Junhu, MD, and Liu Cheng, MD

A Cohort Study of Patients Undergoing Distal Tibial Osteotomy without Fibular Osteotomy for Medial Ankle Arthritis with Mortise WideningTae-Keun Ahn, MD, Young Yi, MD, Jae-Ho Cho, MD, and Woo-Chun Lee, MD, PhD

Low tibial osteotomy for varus-type osteoarthritis of the ankleY. Tanaka, Y. Takakura, K. Hayashi, A. Taniguchi, T. Kumai, K. Sugimoto

Indications for Supramalleolar Osteotomy in Patientswith Ankle Osteoarthritis and Varus Deformity

Woo-Chun Lee, MD, Jeong-Seok Moon, MD, Kang Lee, MD, Woo Jin Byun, MD, and Sang Hyeong Lee, MD

Investigation performed at the Department of Orthopaedic Surgery, Seoul Paik Hospital, Seoul, South Korea

Background: Osteotomies are reported to be effective for the treatment of most cases of primary and traumatic moderateosteoarthritis of the ankle joint. Because of unsatisfactory results following supramalleolar tibial osteotomy in several ofour patients, we investigated the cause of the unsatisfactory results and the indications for this surgical procedure.

Methods: Supramalleolar tibial osteotomy combined with fibular osteotomy was performed in sixteen ankles (sixteenpatients) to treat moderate medial ankle osteoarthritis. The median duration of follow-up was 2.3 years (range, one to 6.5years). Clinical assessment was performed with use of the American Orthopaedic Foot & Ankle Society (AOFAS) scale, andthe osteoarthritis stage was determined radiographically with use of the modified Takakura classification system. Clinicaland radiographic results were compared among groups defined by high (‡9.5�) or low (£4�) postoperative talar tilt and bythe presence or absence of postoperative lateral subfibular pain. The optimal threshold of preoperative talar tilt forpredicting high postoperative talar tilt was determined with use of receiver operating characteristic curve analysis.

Results: The mean AOFAS score, mean Takakura stage, and mean values of all radiographic parameters were improvedsignificantly after surgery. The preoperative talar tilt was correlated with the postoperative talar tilt (Spearman rho = 0.75,p < 0.01). Themean AOFAS score was higher (p = 0.02) and themean radiographic stage was lower (p = 0.03) in the groupwith low postoperative talar tilt than in the group with high talar tilt. The optimal threshold for predicting high postoperativetalar tilt was 7.3� of preoperative talar tilt, with a sensitivity of 100% and a specificity of 91.7%. The patients with lateralsubfibular pain had a lower mean AOFAS score, a greater angle between the tibia and the ankle surface postoperatively,and greater postoperative heel valgus than those without lateral subfibular pain.

Conclusions: Supramalleolar osteotomy is indicated for the treatment of ankle osteoarthritis in patients with minimaltalar tilt and neutral or varus heel alignment.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Surgical realignment procedures can successfully restorenormal joint function or halt further disease progressionin ankles with asymmetric ankle osteoarthritis1-4. Supra-

malleolar osteotomy has been used to restore a more normaljoint geometry in cases of distal tibial malalignment, and thisprocedure has been reported to be effective for the treatment ofprimary as well as traumatic moderate ankle osteoarthritis1,3-6.Supramalleolar osteotomy is designed to shift the weight-bearing axis to the lateral side of the ankle joint and unload themedial side, and it is expected to correct the talar tilt that oftenexists. However, lateral translation and valgus angulation of the

hindfoot can result when amedial opening-wedge osteotomy isused. Although we are not aware of any previous reports ofclinical problems associated with lateral translation of thehindfoot, medial translation of the distal fragment is thought toprevent possible undesirable effects associated with lateral trans-lation of the hindfoot7.

Although supramalleolar osteotomy has been reported tobe successful in most cases1,3,5,6,8, Tanaka et al. concluded thatsupramalleolar osteotomy was not indicated for ankles classi-fied as Stage 3B according to the modified Takakura system, asthe joint space could not be restored to normal in those ankles4.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support ofany aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of thiswork, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, noauthor has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence whatis written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of thearticle.

1243

COPYRIGHT � 2011 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED

J Bone Joint Surg Am. 2011;93:1243-8 d doi:10.2106/JBJS.J.00249


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Supramalleolar OsteotomyWith Bone Marrow Stimulationfor Varus Ankle Osteoarthritis

Clinical Results and Second-Look Arthroscopic Evaluation

Yong Sang Kim,*y MD, Eui Hyun Park,z MD, Yong Gon Koh,y MD,and Jin Woo Lee,§ MD, PhDInvestigation performed at Yonsei Sarang Hospital, Seoul, Korea

Background: Supramalleolar osteotomy (SMO), which redistributes the load line within the ankle joint, has been reported as aneffective treatment for varus ankle osteoarthritis. However, no study has examined cartilage regeneration in the medial compart-ment of the ankle after SMO.

Hypothesis/Purpose: This study aimed to investigate the clinical and radiological outcomes of SMO and to identify the associ-ation between the outcomes of SMO and cartilage regeneration evaluated by second-look arthroscopy. The hypothesis was thatcartilage regeneration would be an important predictor of the outcomes of SMO and that arthroscopic marrow stimulation wouldaid in cartilage regeneration.

Study Design: Case series; Level of evidence, 4.

Methods: A total of 31 ankles were retrospectively evaluated after arthroscopic marrow stimulation with SMO for varus ankleosteoarthritis; second-look arthroscopy was conducted for all these ankles. Clinical outcome measures included a visual analogscale (VAS) for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Radiological outcome variablesincluded the tibial-ankle surface angle (TAS), talar tilt (TT), and tibial-lateral surface angle (TLS), and progression of degenerativearthritis of the ankle was assessed. In the second-look arthroscopy, cartilage regeneration was evaluated using the InternationalCartilage Repair Society (ICRS) grade.

Results: The mean 6 standard deviation VAS and AOFAS scores were 7.1 6 0.8 and 62.9 6 4.0 preoperatively, and they sig-nificantly improved to 3.4 6 1.3 and 83.1 6 7.5, respectively (P \ .001, for both) at the time of the second-look arthroscopy(mean, 13.2 months postoperatively). However, at final follow-up (mean, 27.4 months postoperatively), they were significantlydecreased to 4.1 6 1.6 and 79.9 6 8.0, respectively, compared with the values at second-look arthroscopy (P \ .001, forboth). The mean TAS, TT, and TLS improved significantly after SMO but showed no significant correlation with the clinical out-comes and ICRS grade (P . .05 for all three). At second-look arthroscopy, the ICRS overall repair grades were normal in 1 (3%),nearly normal in 7 (23%), abnormal in 13 (42%), and severely abnormal in 10 (32%). Progressive degenerative arthritis wasobserved in 13 cases (42%). The ICRS grade was significantly associated with the clinical outcomes (P\ .0001) and developmentof degenerative arthritis of the ankle joint (P = .002).

Conclusion: This study showed improved clinical outcomes after SMO for varus ankle osteoarthritis in comparison to the pre-operative assessments. Furthermore, the ICRS grade was significantly associated with the clinical outcomes of SMO at finalfollow-up and significantly associated with the development of degenerative arthritis of the ankle joint. Therefore, arthroscopicmarrow stimulation should be considered with SMO to ensure adequate cartilage regeneration. However, given the ICRS gradesobserved at the time of the second-look arthroscopies and the progression of degenerative arthritis in 42%, the long-term prog-nosis in this group of patients is uncertain.

Keywords: arthroscopic marrow stimulation; supramalleolar osteotomy; varus ankle osteoarthritis; second-look arthroscopy

Asymmetric joint load in the ankle due to varus malalign-ment can lead to progressive joint degeneration in patients

with varus ankle osteoarthritis.5,20,27 For patients withlimited medial osteoarthritis and varus malalignment ofthe ankle, realignment surgery such as supramalleolarosteotomy (SMO), which restores the joint orientationand axial alignment of the ankle, has been used to preservethe ankle from articular degeneration and biomechanicaldysfunction as well as to postpone fusion or replacement

The American Journal of Sports Medicine, Vol. 42, No. 7DOI: 10.1177/0363546514530669� 2014 The Author(s)

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24

Effect of Combined Fibular Osteotomy on the Pressure of the Tibiotalarand Talofibular Joints in Supramalleolar Osteotomy of the Ankle:A Cadaveric Study

Gi Won Choi, MD, PhD 1, Soon Hyuck Lee, MD, PhD 2, Kyung Wook Nha, MD, PhD 3,Sung Jae Lee, PhD 4, Won Hyeon Kim, BE 4, Chang-Sub Uhm, MD, PhD 5

1Department of Orthopaedic Surgery, Korea University Ansan Hospital, Ansan-si, Gyeonggi-do, South Korea2Department of Orthopedic Surgery, Korea University Anam Hospital, Seoul, South Korea3Department of Orthopedic Surgery, Inje University Ilsanpaik Hospital, Goyang-si, Gyeonggi-do, South Korea4Department of Biomedical Engineering, Inje University, Gimhae-si, Gyeongsangnam-do, South Korea5Department of Anatomy, College of Medicine, Korea University, Seoul, South Korea

a r t i c l e i n f o

Level of Clinical Evidence: 5

Keywords:ankle jointjoint contact pressurepressure sensorsupramalleolar osteotomy

a b s t r a c t

We investigated the effect of combined fibular osteotomy on the pressure of the tibiotalar and talofibular jointsin medial opening-wedge supramalleolar osteotomy. Three different tibial osteotomy gaps (6, 8, and 10 mm)were created in 10 cadaveric models, and the pressure in the tibiotalar and talofibular joints was measuredunder axial load before and after fibular osteotomy. The heel alignment angle and talar translation ratio wereevaluated radiographically. An increase in osteotomy gap led to increases in hindfoot valgus (p ¼ .001) and thecontact and peak pressures in the talofibular joint (p ¼ .03 and p ¼ .004). In contrast, the contact and peakpressures in the tibiotalar joint were unchanged with an increasing osteotomy gap (p ¼ .52 and p ¼ .76).Fibular osteotomy reduced the contact and peak pressures in the talofibular joint (p < .001 and p ¼ .001,respectively), and it did not influence the contact and peak pressures in the tibiotalar joint (p ¼ .46 and p ¼ .14,respectively). Therefore, fibular osteotomy might be necessary in supramalleolar osteotomy for medial anklearthritis to minimize the increase in pressure in the talofibular joint, especially when the osteotomy gap islarge.

� 2016 by the American College of Foot and Ankle Surgeons. All rights reserved.

Supramalleolar osteotomy has been used to treat asymmetricankle osteoarthritis with a partially preserved tibiotalar joint surface(1,2). Medial opening-wedge supramalleolar osteotomy to treatmedial ankle arthritis restores joint orientation and causes a load shiftto a portion of the joint that is not involved in the degenerativeprocess, thus, improving ankle function and relieving pain (3–8).

Several clinical studies have reported good results of medialopening-wedge supramalleolar osteotomy with fibular osteotomy formedial ankle arthritis (9,10), but other studies have reported goodresults with medial opening-wedge supramalleolar osteotomywithout fibular osteotomy (11,12). Furthermore, Lee and Cho (13)suggested that their new oblique supramalleolar opening-wedgeosteotomy without fibular osteotomy minimizes the adverse effects

of mortise distortion and enhances osteotomy site stability by thepresence of an intact fibula.

A combined fibular osteotomy in medial opening-wedge supra-malleolar osteotomy might affect the biomechanics of the tibiotalarand talofibular joints. Angular or rotational deformity of the distalfibula plays an important role in determining the contact areas andpressure distribution at the tibiotalar joint. Also, the effect of thefibula on the biomechanics of the tibiotalar joint is more markedwith valgus deformity than with varus (6). The load can be trans-mitted by way of the talofibular joint, and the fibula can take part inthe load transfer, particularly in valgus deformities (5). Lateral sub-fibular pain can develop after medial opening-wedge supramalleolarosteotomy because of valgus angulation and lateral translation of thehindfoot (9).

Although combined fibular osteotomy in medial opening-wedgesupramalleolar osteotomy can biomechanically affect the tibiotalarand talofibular joints, the indication of fibular osteotomy has not beenclearly established. Furthermore, few data have been reportedregarding the biomechanical effects of combined fibular osteotomy.

Financial Disclosure: None reported.Conflict of Interest: None reported.Address correspondence to: Soon Hyuck Lee, MD, PhD, Department of Orthopaedic

Surgery, Korea University Anam Hospital, 73, Inchon-ro, Seongbuk-gu, Seoul 02841,South Korea.

E-mail address: [email protected] (S.H. Lee).

1067-2516/$ - see front matter � 2016 by the American College of Foot and Ankle Surgeons. All rights reserved.http://dx.doi.org/10.1053/j.jfas.2016.08.003

Contents lists available at ScienceDirect

The Journal of Foot & Ankle Surgery

journal homepage: www.j fas .org

The Journal of Foot & Ankle Surgery 56 (2017) 59–64


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Foot & Ankle International®2016, Vol. 37(1) 102 –108© The Author(s) 2015Reprints and permissions: sagepub.com/journalsPermissions.navDOI: 10.1177/1071100715597438fai.sagepub.com

Article

Introduction

Supramalleolar osteotomy (SMO) is an operative procedure to correct congenital or acquired deformities of the distal tibia, ankle, or foot.3 The goal of this procedure is to realign the limb in correcting deformities and to redistribute the loads on the ankle joint, thereby improving the biomechan-ics of the lower extremity.16 Different techniques have been proposed, favoring either opening- or closing-wedge oste-otomies in adults and mostly opening wedge osteotomies in children and adolescents.12,13 Lateral closing wedge osteot-omy has several advantages, including ease of fixation, no graft requirement, reliable and rapid healing, and no possi-bility of medial joint load increase.7 The disadvantages are the necessity of an additional fibular osteotomy and fixation and the possibility of leg-length discrepancy. Medial opening-wedge osteotomy also has advantages, including a

simple approach, ease of bone cuts, and less risk of resultant leg-length discrepancy.7 The potential disadvantages are

597438 FAIXXX10.1177/1071100715597438Foot & Ankle InternationalNha et alresearch-article2015

1Department of Orthopedic Surgery, Inje University Ilsanpaik Hospital, Republic of Korea2Department of Orthopedic Surgery, Korea University Anam Hospital, Republic of Korea3Department of Anatomy, College of Medicine, Korea University, Republic of Korea4Department of Orthopedic surgery, Korea University Guro Hospital, Republic of Korea5Department of Orthopedic Surgery, Soonchunhyang University Bucheon Hospital, Republic of Korea

Corresponding Author:Young Koo Lee, MD, PhD, Department of Orthopedic Surgery, College of Medicine, Soonchunhyang University Bucheon Hospital, 1174 Jung-1-dong, Wonmi-gu, Bucheon-si, Gyunggi-do, 420-767, Republic of Korea. Email: [email protected]


Kyung Wook Nha, MD, PhD1, Soon Hyuck Lee, MD, PhD2, Im Joo Rhyu, MD, PhD3, Hak Jun Kim, MD, PhD4, Jae Gwang Song, MD1, Jae Hwi Han, MD1, Eui Dong Yeo, MD5, and Young Koo Lee, MD, PhD5

AbstractBackground: The purpose of this present study was to determine the incidence of lateral cortical fracture depending on the plane of osteotomy in medial open-wedge supramalleolar osteotomy (SMO) and to define a safe zone through which a medial open-wedge SMO could be performed with minimal risk of lateral cortical fracture.Materials and Methods: Matched pairs of fresh-frozen human cadaver lower leg specimens were obtained from 7 males and 3 females (average age = 63.9 [range 49–75] years). In group A, a safe zone-level medial open-wedge SMO (plane of osteotomy oriented to the proximal one-third of the intrasyndesmosis) was performed, and in group B, a higher-level medial open-wedge SMO (plane of osteotomy oriented to the suprasyndesmosis) was performed.Results: In group A, 7 of the 10 limbs had no lateral cortical fracture, and 3 had lateral cortical fracture, but all of the fractured limbs were stable during the medial open-wedge SMO procedure. In group B, 2 of 10 limbs had no lateral cortical fracture and 8 had lateral cortical fracture. Three of the 8 fractured limbs were stable, but 5 were unstable during the medial open-wedge SMO procedure. The incidence of lateral cortical fracture in group B was significantly higher compared to group A (P = .04).Conclusions: According to the present findings, lateral cortical fracture was less likely to occur when open-wedge SMO was at the plane of the proximal one-third of the intrasyndesmosis, the so-called “safe zone,” than at the plane of the suprasyndesmosis.Clinical Relevance: A safe zone for medial open-wedge SMO to prevent lateral cortical fracture during the medial open-wedge SMO procedure was identified.

Keywords: supramalleolar osteotomy, lateral cortical fracture, safe zone, plane of osteotomy

26

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Article

Introduction

Ankle arthritis is a progressive disease characterized by degeneration of articular cartilage and often develops asym-metrically with a concomitant varus or valgus deformity of the hindfoot.9 Joint-sacrificing procedures including total ankle replacement or ankle arthrodesis are accepted treat-ment for painful end-stage ankle osteoarthritis.6,28 However, because more than half the tibiotalar joint surface is usually preserved in early and midstage ankle osteoarthritis, treat-ment is challenging and leads to some controversy.

Supramalleolar osteotomy (SMOT) is an effective pro-cedure for the treatment of midstage asymmetric ankle osteoarthritis.* This procedure was first introduced by Speed and Boyd in 1936,23 and popularized after Takakura’s

report in 1995.26 For varus ankle osteoarthritis, the purpose of SMOT is to realign the weight-bearing surface of the ankle joint1,19,20; restore the congruence of the tibiotalar joint surface4,18,20; normalize biomechanics to reduce shear forces while restoring gliding movement between the talus and tibia; decrease the contact pressure in the medial part of the tibiotalar joint to postpone the progress of osteoarthri-tis25; and even to reverse the radiologic stages.3,10,26,27

649926 FAIXXX10.1177/1071100716649926Foot & Ankle InternationalHongmou et alresearch-article2016

1Foot and Ankle Surgery Department, Honghui Hospital, Xi’an Jiaotong University College of Medicine, China

Corresponding Author:Liang Xiaojun, MD, Foot and Ankle Surgery Department, Honghui Hospital, Xi’an Jiaotong University College of Medicine, No. 76, Nanguo Road, Xi’an 710054, China. Email: [email protected]

Supramalleolar Osteotomy With or Without Fibular Osteotomy for Varus Ankle Arthritis

Zhao Hongmou, MD, PhD1, Liang Xiaojun, MD1, Li Yi, MD, PhD1, Liu Hongliang, MD1, Wang Junhu, MD1, and Liu Cheng, MD1

AbstractBackground: Supramalleolar osteotomy (SMOT) is an alternative operative procedure for the management of early and midstage varus ankle arthritis. However, whether fibular osteotomy is needed is controversial. The purpose of the current study was to evaluate the functional and radiologic outcomes of pre- and postoperative SMOT, and to compare the outcomes between patients with and without fibular osteotomy.Methods: Forty-one Takakura stage 2 and 3 varus ankle osteoarthritis patients treated with SMOT 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 Orthopaedic Foot & 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 (from 58.3 to 81.6 points) in overall were improved (P < .01); the mean AOS pain (from 42.6 to 26.1 points) and function (from 53.4 to 36.8 points) scores were decreased (P < .01). For radiologic evaluation, all the included parameters were improved (P < .05) except TLS. The mean Takakura stage was decreased (P < .01). No significant difference could be detected in comparing the functional outcomes between those with and without fibular osteotomy. However, in the fibular osteotomy group, TT was decreased (P < .05) and TC was improved (P < .01) significantly.Conclusion: SMOT was promising, with substantial functional improvement and malalignment correction for varus ankle arthritis. Fibular osteotomy may be necessary in cases with large TT and small TC angles.Level of Evidence: Level III, retrospective comparative study.

Keywords: ankle arthritis, realignment surgery, supramalleolar osteotomy

*References 1, 3, 4, 7, 8, 10, 12-15, 18-20, 24, 26, 27.

at UNIV REGINA LIBRARY on June 5, 2016fai.sagepub.comDownloaded from

Foot & Ankle International®2016, Vol. 37(1) 102 –108© The Author(s) 2015Reprints and permissions: sagepub.com/journalsPermissions.navDOI: 10.1177/1071100715597438fai.sagepub.com

Article

Introduction

Supramalleolar osteotomy (SMO) is an operative procedure to correct congenital or acquired deformities of the distal tibia, ankle, or foot.3 The goal of this procedure is to realign the limb in correcting deformities and to redistribute the loads on the ankle joint, thereby improving the biomechan-ics of the lower extremity.16 Different techniques have been proposed, favoring either opening- or closing-wedge oste-otomies in adults and mostly opening wedge osteotomies in children and adolescents.12,13 Lateral closing wedge osteot-omy has several advantages, including ease of fixation, no graft requirement, reliable and rapid healing, and no possi-bility of medial joint load increase.7 The disadvantages are the necessity of an additional fibular osteotomy and fixation and the possibility of leg-length discrepancy. Medial opening-wedge osteotomy also has advantages, including a

simple approach, ease of bone cuts, and less risk of resultant leg-length discrepancy.7 The potential disadvantages are

597438 FAIXXX10.1177/1071100715597438Foot & Ankle InternationalNha et alresearch-article2015

1Department of Orthopedic Surgery, Inje University Ilsanpaik Hospital, Republic of Korea2Department of Orthopedic Surgery, Korea University Anam Hospital, Republic of Korea3Department of Anatomy, College of Medicine, Korea University, Republic of Korea4Department of Orthopedic surgery, Korea University Guro Hospital, Republic of Korea5Department of Orthopedic Surgery, Soonchunhyang University Bucheon Hospital, Republic of Korea

Corresponding Author:Young Koo Lee, MD, PhD, Department of Orthopedic Surgery, College of Medicine, Soonchunhyang University Bucheon Hospital, 1174 Jung-1-dong, Wonmi-gu, Bucheon-si, Gyunggi-do, 420-767, Republic of Korea. Email: [email protected]


Kyung Wook Nha, MD, PhD1, Soon Hyuck Lee, MD, PhD2, Im Joo Rhyu, MD, PhD3, Hak Jun Kim, MD, PhD4, Jae Gwang Song, MD1, Jae Hwi Han, MD1, Eui Dong Yeo, MD5, and Young Koo Lee, MD, PhD5

AbstractBackground: The purpose of this present study was to determine the incidence of lateral cortical fracture depending on the plane of osteotomy in medial open-wedge supramalleolar osteotomy (SMO) and to define a safe zone through which a medial open-wedge SMO could be performed with minimal risk of lateral cortical fracture.Materials and Methods: Matched pairs of fresh-frozen human cadaver lower leg specimens were obtained from 7 males and 3 females (average age = 63.9 [range 49–75] years). In group A, a safe zone-level medial open-wedge SMO (plane of osteotomy oriented to the proximal one-third of the intrasyndesmosis) was performed, and in group B, a higher-level medial open-wedge SMO (plane of osteotomy oriented to the suprasyndesmosis) was performed.Results: In group A, 7 of the 10 limbs had no lateral cortical fracture, and 3 had lateral cortical fracture, but all of the fractured limbs were stable during the medial open-wedge SMO procedure. In group B, 2 of 10 limbs had no lateral cortical fracture and 8 had lateral cortical fracture. Three of the 8 fractured limbs were stable, but 5 were unstable during the medial open-wedge SMO procedure. The incidence of lateral cortical fracture in group B was significantly higher compared to group A (P = .04).Conclusions: According to the present findings, lateral cortical fracture was less likely to occur when open-wedge SMO was at the plane of the proximal one-third of the intrasyndesmosis, the so-called “safe zone,” than at the plane of the suprasyndesmosis.Clinical Relevance: A safe zone for medial open-wedge SMO to prevent lateral cortical fracture during the medial open-wedge SMO procedure was identified.

Keywords: supramalleolar osteotomy, lateral cortical fracture, safe zone, plane of osteotomy


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A Cohort Study of Patients Undergoing Distal TibialOsteotomy without Fibular Osteotomy for Medial

Ankle Arthritis with Mortise WideningTae-Keun Ahn, MD, Young Yi, MD, Jae-Ho Cho, MD, and Woo-Chun Lee, MD, PhD

Investigation performed at the Seoul Foot and Ankle Center, Department of Orthopaedic Surgery,Seoul Paik Hospital, Inje University, Seoul, South Korea

Background: Although the supramalleolar osteotomy can shift the weight-bearing axis laterally, it cannot reconstruct awidened ankle mortise caused by progression of medial ankle osteoarthritis. The aim of this study was to evaluateradiographic and clinical outcomes of distal tibial osteotomy without fibular osteotomy in patients with medial ankleosteoarthritis and mortise widening.

Methods: Distal tibial osteotomy without fibular osteotomy was performed in eighteen patients to treat medial ankleosteoarthritis with mortise widening. Fifteen women and three men with a mean age of fifty-seven years (range, forty-nineto sixty-four years) were followed for a mean of thirty-four months (range, twenty-four to sixty-six months). Mortise wideningwas diagnosed using valgus stress radiographs and intraoperative examination. The clinical outcome was assessed withthe American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analog scale (VAS) score for pain, and the ankleosteoarthritis scale (AOS) score. The translation of the talus within the ankle mortise, talar tilt, medial distal tibial angle,and anterior distal tibial angle were evaluated on weight-bearing radiographs made preoperatively and postoperatively.

Results: The AOFAS score improved significantly from 78.4 points (95% confidence interval [CI], 74.6 to 80.5 points) to89 points (95% CI, 86.5 to 90.5 points) (p < 0.001). The VAS score for pain also decreased significantly from 6.7 points(95% CI, 6 to 7.5 points) to 2.7 points (95% CI, 2.3 to 3.3 points) (p < 0.001). The mean AOS score was 29.8 points (95%CI, 22 to 38.2 points) at the latest follow-up. The center of the talusmoved laterally within the anklemortise after the distaltibial osteotomy. Themeanmedial distal tibial angle changed from 86.6� (95% CI, 85.7� to 87.6�) to 92.9� (95% CI, 91.6�to 94.3�) (p < 0.001), and themean anterior distal tibial angle changed from 81.1� (95% CI, 78.6� to 83.6�) to 84.3� (95%CI, 81.9� to 86.4�) (p < 0.001). However, talar tilt was not corrected significantly (p = 0.916).

Conclusions: Distal tibial osteotomy without fibular osteotomy reduces pain in the short term in patients with anklearthritis, a widened mortise, and minimal talar tilt.

Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Asupramalleolar osteotomy of the tibia and fibula cre-ates angulation and translation of the ankle jointwithout changing the width of the ankle mortise.

When there is ankle osteoarthritis with mortise widening,

supramalleolar osteotomy may not achieve a stable osseousmortise. If the tibia is cut and angled toward the fibulawithout osteotomy of the fibula, a functional narrowing ofthe mortise may occur. Plafondplasty has been suggested as

Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party insupport of an aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior tosubmission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in thiswork. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential toinfluence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with theonline version of the article.

Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editorreviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one ormore exchanges between the author(s) and copyeditors.

381

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J Bone Joint Surg Am. 2015;97:381-8 d http://dx.doi.org/10.2106/JBJS.M.01360

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VOL. 88-B, No. 7, JULY 2006 909

Low tibial osteotomy for varus-type osteoarthritis of the ankle

Y. Tanaka, Y. Takakura, K. Hayashi, A. Taniguchi, T. Kumai, K. Sugimoto

From Nara Medical University, Nara, Japan

�

Y. Tanaka, MD, PhD, Orthopaedic Surgeon, Assistant Professor

�

Y. Takakura, MD, PhD, Orthopaedic Surgeon, Professor and Chairman

�

K. Hayashi, MD, Orthopaedic Surgeon, Clinical Fellow

�

A. Taniguchi, MD, PhD, Orthopaedic Surgeon, Clinical Fellow

�

T. Kumai, MD, PhD, Orthopaedic Surgeon, Assistant Professor

�

K. Sugimoto, MD, PhD, Orthopaedic Surgeon, Assistant ProfessorDepartment of Orthopaedic SurgeryNara Medical University, Kashihara, Nara 634-8522, Japan.

Correspondence should be sent to Dr Y. Tanaka; e-mail: [email protected]

©2006 British Editorial Society of Bone and Joint Surgerydoi:10.1302/0301-620X.88B7. 17325 $2.00

J Bone Joint Surg [Br]

2006;88-B:909-13.

Received 19 October 2005; Accepted after revision 1 March 2006

In this retrospective study we have assessed the results of low tibial valgus osteotomy for varus-type osteoarthritis of the ankle and its indications.

We performed an opening wedge osteotomy in 25 women (26 ankles). The mean follow-up was for eight years and three months (2 years 3 months to 17 years 11 months).

Of the 26 ankles, 19 showed excellent or good clinical results. Their mean scores for pain, walking, and activities of daily living were significantly improved but there was no change in the range of movement. In the ankles which were classified radiologically as stage 2 according to our own grading system, with narrowing of the medial joint space, and in 11 as stage 3a, with obliteration of the joint space at the medial malleolus only, the joint space recovered. In contrast, such recovery was seen in only two of 12 ankles classified as stage 3b, with obliteration of the joint space advancing to the upper surface of the dome of the talus. Low tibial osteotomy is indicated for varus-type osteoarthritis of stage 2 or stage 3a.

Osteoarthritis of the ankle has various causes,of which malunited and intra-articular frac-tures are the most common.

1,2

Adult flat footmay predispose to valgus-type osteoarthritis

3

and idiopathic varus osteoarthritis is alsorecognised.

4,5

Since 1982 we have undertakenlow tibial valgus osteotomy for this type ofosteoarthritis and reported good results inpatients with symptoms of intermediate sever-ity.

6

However, since the number of patients hasincreased, we have encountered those in whomthe operation has failed. This study was carriedout to clarify the limitations of the operation.To exclude the effects of different techniques,we limited analysis to patients who had under-gone opening wedge osteotomy.

Patients and Methods

Between 1987 and 2002, 25 patients (26 feet)with varus-type osteoarthritis of the ankle hada low tibial osteotomy in our hospital.Although one died and three were lost to fol-low-up, their records contained sufficientdetail for assessment. All were women, with amean age of 54 years (37 to 76). The mean fol-low-up was eight years three months (2 years 3months to 17 years 11 months).

Varus-type osteoarthritis of the ankle is clas-sified into four stages:

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1) no narrowing of thejoint-space, but early sclerosis and formationof osteophytes; 2) narrowing of the medialjoint space; 3) obliteration of this space with

subchondral bone contact and 4) obliterationof the whole joint space with complete bonecontact. In this study, stage 3 was further clas-sified into stage 3a and 3b. In the former, oblit-eration of the joint space was limited to themedial malleolus and in the latter, the oblitera-tion extended to the roof of the dome of thetalus (Fig. 1). In our study, three joints were instage 2, 11 in 3a and 12 in 3b.

Before operation weight-bearing antero-posterior (AP) and lateral radiographs weretaken. The angle between the tibial shaft andits distal joint surface on the AP view (TASangle) and the same angle on the lateral view(TLS angle) were measured.

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They indicatedthe angle of varus and the amount of anterioropening of the joint. In normal Japanese sub-jects, the mean TAS and TLS angles are 88.1˚and 81.0˚, respectively.

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The tibial axis wasdefined as the line between the midpoints ofthe tibial shaft 8 cm and 13 cm above the tip ofthe medial malleolus. In a previous series weaimed to achieve a TAS angle of between 93˚and 94˚ and a TLS angle of 81˚ or 82˚.

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How-ever, since then we have recognised that over-correction of varus gave better results thanundercorrection, especially for advanced osteo-arthritis. Therefore, we now aim for a TASangle of 96˚ to 98˚ with a TLS angle similar tobefore. We used an anteromedial openingwedge osteotomy to correct the varus andanterior opening of the distal joint surface.

Lower limb

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2018 Ankle SMO Pilon Fx. - OhtoMedical