Surgical Treatment of the Arthritic Varus Ankle

doi:10.1016/j.fcl.2012.09.002

Foot and Ankle Clinics

Volume 17, Issue 4, December 2012, Pages 665-686

https://doi.org/10.1016/j.fcl.2012.09.002 Get rights and content

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Key Points

•
Surgical correction of the varus arthritic ankle is challenging; rarely does an isolated procedure provide satisfactory outcome.
•
Many of the principles applied to joint-preserving realignment procedures may be applied to total ankle arthroplasty.
•
Varus ankle arthritis exists on a continuum that prompts the treating surgeon to be familiar with a spectrum of surgical solutions, including joint-sparing realignment, arthroplasty, and arthrodesis.

Evaluation

Apostle and Sangeorzan⁹ and Thevendran and Younger¹⁰ recently reviewed the anatomy and examination of the varus ankle, respectively. The reader is strongly urged to read these important interpretations of the salient features of the varus ankle; their insight provides a valuable foundation for this review. In addition, Easley and Vineyard¹¹ recently published a review article on varus ankle deformity. The following paragraphs borrow from this article to summarize what was deemed important in

Case I

A 38-year-old man presented with severe incongruent tibiotalar varus associated with cavus foot deformity. The patient failed to improve with bracing. A supramalleolar osteotomy was performed in combination with soft tissue rebalancing and realignment osteotomies of the foot, as recommended by Knupp and colleagues¹⁸ The patient had a marked reduction in pain and no longer experienced symptomatic lateral foot overload (Fig. 1).

Case IA

A 63-year-old man presented with similar deformity to the patient in

Joint-Sparing Procedures

Knupp and colleagues¹⁸ recently reported on 94 supramalleolar osteotomies (92 patients) for ankle arthritis, with 33 supramalleolar osteotomies being performed for varus ankle arthritis. Additional procedures in the varus group included fibular osteotomy (n = 6), calcaneal osteotomy (n = 6), midfoot osteotomy/arthrodesis (n = 5), lateral ligament repair (n = 18), and medial ligament repair (n = 3). The investigators corrected varus deformity with a medial opening wedge osteotomy for varus

Summary

Surgical correction of the varus arthritic ankle is challenging and rarely does an isolated procedure provide satisfactory outcome. Many principles applied to joint-preserving realignment procedures may be applied to TAA. Comprehensive ankle and foot realignment may relieve symptoms in most patients with varus ankle arthritis, but intra-articular distortion often does not allow for physiologic correction in joint-sparing surgery. Although considerable correction may be achieved with isolated

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We investigated the effect of combined fibular osteotomy on the pressure of the tibiotalar and talofibular joints in 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 measured under axial load before and after fibular osteotomy. The heel alignment angle and talar translation ratio were evaluated radiographically. An increase in osteotomy gap led to increases in hindfoot valgus (p = .001) and the contact and peak pressures in the talofibular joint (p = .03 and p = .004). In contrast, the contact and peak pressures in the tibiotalar joint were unchanged with an increasing osteotomy gap (p = .52 and p = .76). Fibular osteotomy reduced the contact and peak pressures in the talofibular joint (p < .001 and p = .001, respectively), and it did not influence the contact and peak pressures in the tibiotalar joint (p = .46 and p = .14, respectively). Therefore, fibular osteotomy might be necessary in supramalleolar osteotomy for medial ankle arthritis to minimize the increase in pressure in the talofibular joint, especially when the osteotomy gap is large.
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