Supramalleolar Distal Tibiofibular Osteotomy for Medial Ankle Osteoarthritis: Current Concepts

Abstract

The supramalleolar osteotomy is a joint-preserving surgical procedure. It is a very good treatment option for the asymmetric varus ankle and medial compartment osteoarthritis. The primary objective of the procedure is to shift medial concentration of stress toward the lateral intact articular cartilage to redistribute the joint loads during ambulation. Several studies have shown that deformities of the ankle result in uneven load distribution in the ankle joint, which eventually leads to articular cartilage degeneration. Since the lateral articular cartilage is intact, joint-sacrificing procedures such as total ankle replacement or ankle arthrodesis are not the most appropriate treatment choices for medial compartment arthritis. Results of supramalleolar osteotomies are very promising in terms of functional outcome and pain relief. In younger patients with medial compartment varus ankle osteoarthritis or even with a normal tibial anterior surface angle, supramalleolar osteotomies can be performed to realign the ankle to promote regeneration of the asymmetrically damaged cartilage. In this review article, we will discuss the indications, complications, surgical techniques, and outcomes of the supramalleolar osteotomy reported in the current literature.

Keywords: Ankle joint; Medial compartment arthritis; Supramalleolar osteotomy.

Fig. 1. Focal static and dynamic overload in the medial compartment, especially the medial gutter.

Fig. 2. Lateral view demonstrating measurement of the tibial lateral surface (TLS) angle.

Fig. 3. Radiographic assessment of the foot and ankle. Concomitant deformities of the lower extremity were assessed on weight-bearing radiographs including the anteroposterior view of the ankle (A), ankle mortise (B), lateral view of the ankle (C), and whole leg radiograph (D).

Fig. 4. Arthroscopic examination of the denuded tibiotalar articular cartilage of the ankle and synovectomy were performed before the supramalleolar osteotomy procedure.

Fig. 5. Fluoroscopic images showing the level of oblique tibial osteotomy using a Kirschner-wire and the osteotomy performed using the oscillating saw.

Fig. 6. Eight-month postoperative weight-bearing ankle radiographs showing osseous healing at the distal tibia medial opening-wedge osteotomy site and the valgus angulated distal fibular osteotomy site with an increased tibial anterior surface angle and the medial gutter space.

Fig. 7. A 37-year-old woman had posttraumatic 28° varus ankle osteoarthritis and a tibial anterior surface angle of 59° after an ankle fracture that had occurred 30 years ago. She complained of medial ankle pain (visual analog scale 5). She was treated with a lateral closing-wedge osteotomy of the tibia and fibula. Preoperative (A) and postoperative (B) radiographs.

Fig. 8. A 68-year-old female patient with medial ankle osteoarthritis (OA) underwent supramalleolar osteotomy (SMO). (A) Preoperative anteroposterior view of the ankle showing medial gutter OA with Takakura stage IIIA. (B) Postoperative 1-year radiograph showing realignment with improvement to stage II. (C) Postoperative 2-year radiograph. (D) Full exposure of the medial talar subchondral bone before the SMO (grade 4). (E) Regeneration of the talar dome articular cartilage at 12 months after SMO (grade 2).