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Lateral closing wedge osteotomy. a Pre-operative weight-bearing radiographs show varus tilting of the talus within the mortise and degenerative changes of the medial tibiotalar joint and the subtalar joint. Saltzman view shows the varus hindfoot alignment. b Supramalleolar lateral closing wedge osteotomy, corrective osteotomy of the fibula and valgisation subtalar arthrodesis were performed. Post-operative weight-bearing radiographs show completed osseous healing at the site of osteotomies and subtalar arthrodesis. Saltzman view shows normal hindfoot alignment
Source publication
Patients with varus or valgus hindfoot deformities usually present with asymmetric ankle osteoarthritis. In-vitro biomechanical studies have shown that varus or valgus hindfoot deformity may lead to altered load distribution in the tibiotalar joint which may result in medial (varus) or lateral (valgus) tibiotalar joint degeneration in the short or...
Similar publications
Various types of re-alignment surgery are used to preserve the ankle joint in cases of intermediate ankle arthritis with partial joint space narrowing.
The short-term and mid-term results after re-alignment surgery are promising, with substantial post-operative pain relief and functional improvement that is reflected by high rates of patient satisf...
Citations
... It is clear that some guidelines or standards are necessary for establishing a successful treatment designation. As it is well established that any imbalance in tibiotalar tilt produces a significant risk for progressive arthritis and ligamentous failure, the common goal should be to return the ankle to its normal anatomical position [17,21,22]. It has been observed in 98% of ankles that it is normal to have <2° of tilt, with >2° indicating a high probability of significant injury/reinjury to the deltoid ligament [23]. ...
... Malalignment may cause overloading of specific areas at the ankle and increase the risk for the development of ankle OA (136). Correcting osteotomies can normalize the cartilage load and restore biomechanics (137,138) but most studies on alignment correction deal with posttraumatic or congenital malalignment (139). In cartilage reconstruction, there is often limited information on additional procedures. ...
The working group ‘Clinical Tissue Regeneration’ of the German Society of Orthopedics and Traumatology (DGOU) issues this paper with updating its guidelines.
Literature was analyzed regarding different topics relevant to osteochondral lesions of the talus (OLT) treatment. This process concluded with a statement for each topic reflecting the best scientific evidence available with a grade of recommendation. All group members rated the statements to identify possible gaps between literature and current clinical practice.
Fixation of a vital bony fragment should be considered in large fragments. In children with open physis, retrograde drilling seems to work better than in adults, but even there, the revision rate reaches 50%. The literature supports debridement with bone marrow stimulation (BMS) in lesions smaller than 1.0 cm² without bony defect. The additional use of a scaffold can be recommended in lesions larger than 1.0 cm². For other scaffolds besides AMIC®/Chondro-Gide®, there is only limited evidence. Systematic reviews report good to excellent clinical results in 87% of the patients after osteochondral transplantation (OCT), but donor site morbidity is of concern, reaching 16.9%. There is no evidence of any additional benefit from autologous chondrocyte implantation (ACI). Minced cartilage lacks any supporting data. Metallic resurfacing of OLT can only be recommended as a second-line treatment. A medial malleolar osteotomy has a minor effect on the clinical outcome compared to the many other factors influencing the clinical result.
... 3 Adjunct treatment strategies include corrective osteotomies in patients with axial malalignment. 3,4 Moreover, OCLA can be associated with an acute ligament injury and chronic ankle instability. [5][6][7][8][9][10] In such cases, the treatment strategy should include stabilization procedures for the ankle. ...
Objective
To assess the current treatment of osteochondral lesions of the ankle (OCLA) by German-speaking foot and ankle surgeons, focusing on the management of postoperative care and rehabilitation.
Design
A questionnaire was created by a panel of 4 experienced foot and ankle surgeons on behalf of the “Clinical Tissue Regeneration” (CTR) working group of the German Society of Orthopaedics and Trauma Surgery (DGOU), and distributed electronically to members of the CTR, participants of the German Cartilage Registry (Knorpelregister DGOU©), and members of 6 German-speaking orthopedics or sports medicine societies. Results were classified depending on the consensus within the answers (agreement ≥75% “strong tendency,” 50%-74% “tendency,” 25%-49% “weak tendency,” <25% “no tendency”).
Results
A total of 60 participants returned the questionnaire. The main results are as follows: regarding the frequency of surgical procedures for OCLA, refixation of the fragment, retrograde drilling, and bone marrow stimulation with or without using a matrix were performed by at least 75% of the surgeons and was considered a strong tendency. There was a strong tendency to stabilize the ankle (76.7%) and perform corrective osteotomies (51.7%). In total, 75.5% and 75% of the surgeons performed bone marrow stimulation with and without using a matrix, respectively. Corrective osteotomy and ankle stabilization were performed in 64.5% and 65.2% cases, respectively. Most participants included published recommendations on postoperative rehabilitation and the return to sports activities in their postoperative management. The main surgical procedures were considered the most critical factor in influencing the postoperative management by 81% of the participants (strong tendency). Adjunct surgical procedures such as corrective osteotomy and stabilization of the ankle were considered important by 67.8% of the respondents (tendency).
Conclusions
The management of OCLA varies among German-speaking foot and ankle surgeons. Therefore, guidelines remain essential to standardize the management of OCLA, to achieve improved and stable results. This survey will assist clinicians and patients with rehabilitation to return to sports after treating the ankle’s cartilage injury.
... Las recomendaciones actuales surgen de opiniones de expertos y la experiencia clínica. En líneas generales, se busca una sobrecorrección de entre 2 y 5° ( 18) . En uno de los pocos estudios donde se analiza la correlación de la corrección del TAS con los resultados funcionales, en un metaanálisis de Beijk et al. (19) , no encontraron diferencias de los resultados funcionales en función del grado de corrección. ...
... However, there are different rationales for the two techniques. In contrast to total ankle arthroplasty, the primary indication for medial open SMO is a varus ankle osteoarthritis with at least 50% of its original integrity in the lateral department [18,35]. It was also thought that clinical outcomes of total ankle replacement only depended on position of prosthesis components but also the alignment [36]. ...
The purpose of this study was to investigate the changes in clinical outcomes and alignment of the ipsilateral knee and ankle in patients with varus ankle osteoarthritis after supramalleolar osteotomy (SMO).
We retrospectively reviewed 23 patients (24 ankles) with Takakura II, IIIa and IIIb ankle osteoarthritis treated with SMO between May 2017 and March 2022. The radiologic parameters of ankles contained medial distal tibial angle (TAS), tibiotalar angle (TT), tibial lateral surface (TLS), tibial plafond inclination (TPI) and talar inclination (TI). The radiologic parameters of knees contained medial proximal tibial angle (MPTA), joint line convergence angle (JLCA), the knee joint line orientation relative to ground (G-KJLO) and WBL. Hip–knee–ankle angle (HKA) was also collected. The Takakura system was used for evaluating the ankle osteoarthritis and the Kellgren–Lawrence (KL) system was used for evaluating the knee osteoarthritis. Clinical evaluation of the ankle joints contained American Orthopedic Foot and Ankle Society (AOFAS), range of motion (ROM) and visual analogue scale (VAS). Clinical evaluation of the knee joints contained Japanese Orthopaedic Association Scores (JOA), ROM, VAS.
The mean follow-up times were 20.3 ± 7.3 months (range 12–38). According to the radiologic evaluation, the TAS increased from preoperative 84.7° ± 2.0° to 91.2° ± 1.8° at the last follow-up (P < 0.001). The TPI and TI decreased from 4.4° ± 4.2° and 11.0° ± 5.2° to 0.1° ± 4.7° and 4.1° ± 4.8° (P < 0.001 for both). The TT angel improved from 9.5° ± 4.1° to 4.9° ± 3.3° (P < 0.001). No significant differences were found regarding MPTA, JLCA, G-KJLO, knee WBL and HKA (P > 0.05 for all). The Takakura stage improved after SMO (P < 0.001) whilst the KL stage maintains the similar lever (P > 0.05). According to the clinical evaluation, the AOFAS significantly increased from 67.5 ± 10.6 to 88.5 ± 9.3 and the VAS of the ankle decreased from 4.7 ± 1.6 to 1.2 ± 1.1, whilst there were no changes on VAS and even the JOA and knee ROM after SMO (P > 0.05 for all).
SMO can alleviate the symptoms of varus ankle osteoarthritis and delay the time for ankle replacement or arthrodesis by redistributing the abnormal stress of the ankle and restoring the congruence of the tibiotalar joint. In addition, it did not induce the clinical symptoms of knee without compromising lower limb alignment or knee joint line orientation in the short term.
Level IV case series.
... Abnormal biomechanics might affect the results and should be addressed before PRP application. Though existing literatures showed benefits of corrective osteotomy associated with ankle OA [34], the additive effect of PRP injection following these joint preserving surgeries has not been investigated. Numerous classifications of ankle OA are not designed specifically to associate with the primary or secondary causes. ...
Background
Platelet-rich plasma (PRP) injection for ankle osteoarthritis (OA) treatment showed contradictory results. This review was aimed to pool individual studies which assessed the efficacy of PRP for ankle OA treatment.
Methods
This study was conducted following the preferred report items of systematic review and meta-analysis guideline. PubMed and Scopus were searched up to January 2023. Meta-analysis, or individual randomised controlled trial (RCT), or observational studies were included if they involved ankle OA with aged ≥ 18 years, compared before–after receiving PRP, or PRP with other treatments, and reported visual analog scale (VAS) or functional outcomes. Selection of eligible studies and data extraction were independently performed by two authors. Heterogeneity test using Cochrane Q test and the I²-statistic were assessed. Standardised (SMD) or unstandardised mean difference (USMD) and 95% confidence interval (CI) were estimated and pooled across studies.
Results
Three studies from meta-analysis and two individual studies were included, which consisted of one RCT and four before–after studies with 184 ankle OAs and 132 PRP. The average age was 50.8–59.3 years, and 25–60% of PRP injected cases were male. The number of primary ankle OA was accounted to 0–100%. When compared to before treatment, PRP significantly reduced VAS and functional score at 12 weeks with pooled USMD of − 2.80, 95% CI − 3.91, − 2.68; p < 0.001 (Q = 82.91, p < 0.001; I² 96.38%), and pooled SMD of 1.73, 95% CI 1.37, 2.09; p < 0.001 (Q = 4.87, p = 0.18; I² 38.44%), respectively.
Conclusion
PRP may beneficially improve pain and functional scores for ankle OA in a short-term period. Its magnitude of improvement seems to be similar to placebo effects from the previous RCT. A large-scale RCT with proper whole blood and PRP preparation processes is required to prove treatment effects.
Trial registration PROSPERO number CRD42022297503.
... In the largest prospective study of 294 patients, the 5-year osteotomy survival rate was 88% (95% CI 84-92%) [26]. The latter seems to support the theoretical concept that joint preserving realignment surgery may restore near normal ankle biomechanics, slowing down the degenerative process, off-loading the damaged cartilage and offering pain relief and functional improvement [20,[30][31][32][33]. According to Krahenbuhl et al. [26], the rate of revision surgeries has a bimodal distribution (2 and 12 years after the corrective osteotomy) and has attributed the early rise in revision surgeries to vague patient selection and the late one to the progression of ankle OA. ...
... According to Krahenbuhl et al. [26], the rate of revision surgeries has a bimodal distribution (2 and 12 years after the corrective osteotomy) and has attributed the early rise in revision surgeries to vague patient selection and the late one to the progression of ankle OA. Furthermore, should TAR be required patients may benefit from previous realignment surgery, as TAR performed in well-aligned feet is less challenging and has been associated with better outcomes [32,[34][35][36][37][38]. The only comparative study of SMOs versus AA showed improvements in function, pain, alignment, and quality of life after surgery for both treatment in cases of advanced arthritis [39]. ...
Introduction
We investigated the mid-term outcomes of supramalleolar osteotomies regarding “survivorship” [before ankle arthrodesis (AA) or total ankle replacement (TAR)], complication rate and adjuvant procedures required.
Material and methods
PubMed, Cochrane and Trip Medical Database were searched from January 01, 2000. Studies reporting on SMOs for ankle arthritis, in minimum of 20 patients aged 17 or older, followed for a minimum of two years, were included. Quality assessment was performed with the Modified Coleman Methodology Score (MCMS). A subgroup analysis of varus/valgus ankles was performed.
Results
Sixteen studies met the inclusion criteria, with 866 SMOs in 851 patients. Mean age of patients was 53.6 (range 17–79) years, and mean follow-up was 49.1 (range 8–168) months. Of the arthritic ankles (646 ankles), 11.1% were classified as Takakura stage I, 24.0% as stage II, 59.9% as stage III and 5.0% as stage IV. The overall MCMS was 55.2 ± 9.6 (fair). Eleven studies (657 SMOs) reported on “survivorship” of SMO, before arthrodesis (2.7%), or total ankle replacement (TAR) (5.8%) was required. Patients required AA after an average of 44.6 (range 7–156) months, and TAR after 36.71 (range 7–152) months. Hardware removal was required in 1.9% and revision in 4.4% of 777 SMOs. Mean AOFAS score was 51.8 preoperatively, improving to 79.1 postoperatively. Mean VAS was 6.5 preoperatively and improved to 2.1 postoperatively. Complications were reported in 5.7% (44 out of 777 SMOs). Soft tissue procedures were performed in 41.0% (310 out of 756 SMOs), whereas concomitant osseous procedures were performed in 59.0% (446 out of 756 SMOs). SMOs performed for valgus ankles failed in 11.1% of patients, vs 5.6% in varus ankles (p < 0.05), with disparity between the different studies.
Conclusions
SMOs combined with adjuvant, osseous and soft tissue, procedures, were performed mostly for arthritic ankles of stage II and III, according to the Takakura classification and offered functional improvement with low complication rate. Approximately, 10% of SMOs failed and patients required AA or TAR, after an average of just over 4 years (50.5 months) after the index surgery. It is debatable whether varus and valgus ankles treated with SMO reveal different success rates.
... Jointpreserving procedures include osteochondral autograft/ allografts, corticoperiosteal grafts, Hemi-CAP, autologous chondrocyte implantation, and supramalleolar osteotomies. 3,4,10,16 Osteochondral autografts have the theoretical advantage of providing viable chondrocytes, an intact hyaline chondral surface, and inherent stability based on the bone-to-bone union. 11 Conversely, the procedure presents disadvantages such as donor site morbidity, limited availability, and potential fibrocartilage formation with the native talus interphase. ...
... 14 However, the functional impairment produced after eliminating the joint limits its indications, jeopardizing patients' satisfaction and expectations. 3 Furthermore, sacrificing the entire joint because of an osteochondral injury may seem to be an excessive surgery. 8 Conversely, total ankle replacement is equally effective in reducing pain compared with ankle arthrodesis but offers the advantage of preserving mobility and maintaining function, theoretically diminishing hindfoot joint degeneration. ...
Background
Ankle hemiarthroplasty is a 1-piece implant system replacing the talar side of the tibiotalar joint. Hemiarthroplasty offers limited bone resection and may provide easier revision options than joint-ablating procedures.
Methods
Prospective, multicenter, noncomparative, nonrandomized clinical study with short term follow-up on patients undergoing hemiarthroplasty of the ankle. Radiologic and functional outcomes (Foot and Ankle Outcome Score FAOS, Foot and Ankle Ability Measure [FAAM], Short Form–36 Health Survey [SF-36], Short Musculoskeletal Functional Assessment [SMFA], and visual analog scale [VAS] pain scores) were obtained at 3 and 12 months and the last follow-up (mean 31.9 months).
Results
Ten patients met the inclusion criteria. Three were converted to total ankle replacement at 14, 16, and 18 months. Pain VAS scores improved on average from 6.8 to 4.8 ( P = .044) of the remaining 7 at a mean of 31.9 months’ follow-up. For these 7 in the Survival Group, we found that SF-36 physical health component improved from 25.03 to 42.25 ( P = .030), SMFA dysfunction and bother indexes improved from 46.36 to 32.28 ( P = .001), and from 55.21 to 30.14 ( P = .002) in the Survival Group, and FAAM sports improved from 12.5 to 34.5 ( P = .023).
Conclusion
Patients undergoing hemiarthroplasty of the ankle joint for talar-sided lesions had a 30% failure rate by 18 months. Those who did not have an early failure exhibited modest pain reduction, functional improvements, and better quality of life in short-term follow-up. This procedure offers a possible alternative for isolated talar ankle cartilage cases.
Level of Evidence
Level IV, prospective case series.
... Ankle osteoarthritis (OA) affects about 1% of the world's adult population [1], causing an important socioeconomic impact on patients and health systems [2,3]. Unlike the hip and the knee, ankle OA is reported in about 80% of the cases related to trauma [4,5], and a part of the population involved is represented by active and high-performance-demanding patients, with a large part younger than 50 years [1]. ...
... About 80% of ankle OA has a post-traumatic origin, such as articular fractures or repeated trauma [9,10]. The fractures that can lead to an asymmetric valgus ankle are represented by the distal diaphysis of the tibia, tibial plafond, and distal fibular fractures [3]. Another frequent cause of valgus ankle osteoarthritis is repeated ankle sprains with associated insufficiency of the deltoid ligament complex [11]. ...
... In the literature, authors routinely reported weight-bearing standardized radiographs for radiographic evaluation. These require anteroposterior and lateral views of the ankle and lateral and dorsoplantar views of the foot [3,22]. Besides, it is also useful to perform a mortise view of the tibiotalar joint [14]. ...
Osteoarthritis (OA) of the ankle affects about 1% of the world’s adult population, causing an important impact on patient lives and health systems. Most patients with ankle OA can show an asymmetrical wear pattern with a predominant degeneration of the medial or the lateral portion of the joint. To avoid more invasive ankle joint sacrificing procedures, joint realignment surgery has been developed to restore the anatomy of the joints with asymmetric early OA and to improve the joint biomechanics and symptoms of the patients. This narrative, comprehensive, all-embracing review of the literature has the aim to describe the current concepts of joint preserving and reconstructive surgery in the treatment of the valgus and varus ankle early OA, through an original iconography and clear indications and technical notes.
... The lateral talar-1st metatarsal angle is an index of midfoot deformity magnitude. Pes planus is defined as a downward convex angle larger than 4° [22]. ...
Ankle deformity is a disabling condition especially if concomitant with osteoarthritis (OA). Varus ankle OA is one of the most common ankle OA deformities. This deformity usually leads to unequal load distribution in the ankle joint and decreases joint contact surface area, leading to a progressive degenerative arthritic situation. Varus ankle OA might have multiple causative factors, which might present as a single isolated factor or encompassed together in a single patient. The etiologies can be classified as post-traumatic (e.g., after fractures and lateral ligament instability), degenerative, systemic, neuromuscular, congenital, and others. Treatment options are determined by the degree of the deformity and analyzing the pathology, which range from the conservative treatments up to surgical interventions. Surgical treatment of the varus ankle OA can be classified into two categories, joint-preserving surgery (JPS) and joint-sacrificing surgery (JSS) as total ankle arthroplasty and ankle arthrodesis. JPS is a valuable treatment option in varus ankle OA, which should not be neglected since it has showed a promising result, optimizing biomechanics and improving the survivorship of the ankle joint.
