Effectiveness and risk factors of supramalleolar osteotomy in treatment of varus-type ankle arthritis_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

LIANG Jingqi ¹ , YANG Xinquan ¹ , YUE Yang ² , FENG Hui ² , LIU Liang ¹ , ZHANG Yan ¹ , LIU Peilong ¹ ,  ZHAO Hongmou ¹

1. Department of Foot and Ankle Surgery, Honghui Hospital of Xi’an Jiaotong University, Xi’an Shaanxi, 710054, P. R. China;
2. Xi’an Medical University, Xi’an Shaanxi, 710016, P. R. China;

Corresponding?author：

ZHAO Hongmou, Email: zhao_hongmou@hotmail.com

Keywords：

Ankle arthritis; supramalleolar osteotomy; complication; risk factor

DOI：

10.7507/1002-1892.202303008

Video：

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Objective To assess the effectiveness of supramalleolar osteotomy (SMOT) as a therapeutic intervention for varus-type ankle arthritis, while also examining the associated risk factors that may contribute to treatment failure. Methods The clinical data of 82 patients (89 feet) diagnosed with varus-type ankle arthritis and treated with SMOT between January 2016 and December 2020 were retrospectively analyzed. The patient cohort consisted of 34 males with 38 feet and 48 females with 51 feet, with the mean age of 54.3 years (range, 43-72 years). The average body mass index was 24.43 kg/m² (range, 20.43-30.15 kg/m²). The preoperative tibial anterior surface angle (TAS) ranged from 77.6° to 88.4°, with a mean of 84.4°. The modified Takakura stage was used to classify the severity of the condition, with 9 feet in stage Ⅱ, 41 feet in stage Ⅲa, and 39 feet in stage Ⅲb. Clinical functional assessment was conducted using the Maryland sore, visual analogue scale (VAS) score, and psychological and physical scores in Health Survey 12-item Short From (SF-12). Radiology evaluations include TAS, talar tilt (TT), tibiocrural angle (TC), tibial medial malleolars (TMM), tibiocrural distance (TCD), tibial lateral surface angle (TLS), and hindfoot alignment angle (HAA). The results of clinical failure, functional failure, and radiology failure were statistically analyzed, and the related risk factors were analyzed. Results The operation time ranged from 45 to 88 minutes, with an average of 62.2 minutes. No complication such as fractures and neurovascular injuries was found during operation. There were 7 feet of poor healing of the medial incision; 9 pin tract infections occurred in 6 feet using external fixator; there were 20 cases of allograft and 3 cases of autograft with radiographic bone resorption. Except for 1 foot of severe infection treated with bone cement, the remaining 88 feet were primary healing, and the healing area was more than 80%. All patients were followed up 24-82 months, with an average of 50.2 months. Maryland score, VAS score, SF-12 psychological and physiological scores, and TAS, TC, TLS, TCD, TT, TMM, HAA, and Takakura stage were significantly improved at last follow-up (P<0.05). Postoperative clinical failure occurred in 13 feet, functional failure in 15 feet, and radiology failure in 23 feet. Univariate analysis showed that obesity, TT>10°, and Takakura stage Ⅲb were risk factors for clinical failure, HAA≥15° and Takakura stage Ⅲb were risk factors for functional failure, and TT>10° was risk factor for radiographic failure (P<0.05). Further logistic regression analysis showed that TT>10°, HAA≥15°, and TT>10° were risk factors for clinical failure, functional failure, and radiographic failure, respectively (P<0.05). Conclusion SMOT is effective in the mid- and long-term in the treatment of varus-type ankle arthritis, but it should be used with caution in patients with obesity, severe hindfoot varus, severe talus tilt, and preoperative Takakura stage Ⅲb.

Citation： LIANG Jingqi, YANG Xinquan, YUE Yang, FENG Hui, LIU Liang, ZHANG Yan, LIU Peilong, ZHAO Hongmou. Effectiveness and risk factors of supramalleolar osteotomy in treatment of varus-type ankle arthritis. Chinese Journal of Reparative and Reconstructive Surgery, 2023, 37(7): 788-795. doi: 10.7507/1002-1892.202303008 Copy

1.	Horisberger M, Hintermann B, Valderrabano V. Alterations of plantar pressure distribution in posttraumatic end-stage ankle osteoarthritis. Clin Biomech (Bristol, Avon), 2009, 24(3): 303-307.
2.	Haraguchi N, Ota K, Tsunoda N, et al. Weight-bearing-line analysis in supramalleolar osteotomy for varus-type osteoarthritis of the ankle. J Bone Joint Surg (Am), 2015, 97(4): 333-339.
3.	Hintermann B, Ruiz R, Barg A. Novel double osteotomy technique of distal tibia for correction of asymmetric varus osteoarthritic ankle. Foot Ankle Int, 2017, 38(9): 970-981.
4.	Hongmou Z, Xiaojun L, Yi L, et al. Supramalleolar osteotomy with or without fibular osteotomy for varus ankle arthritis. Foot Ankle Int, 2016, 37(9): 1001-1007.
5.	Zhao HM, Liang XJ, Li Y, et al. Supramalleolar osteotomy with distraction arthroplasty in treatment of varus ankle osteoarthritis with large talar tilt angle: A case report and literature review. J Foot Ankle Surg, 2017, 56(5): 1125-1128.
6.	Takakura Y, Tanaka Y, Kumai T, et al. Low tibial osteotomy for osteoarthritis of the ankle. Results of a new operation in 18 patients. J Bone Joint Surg (Br), 1995, 77(1): 50-54.
7.	Tanaka Y, Takakura Y, Hayashi K, et al. Low tibial osteotomy for varus-type osteoarthritis of the ankle. J Bone Joint Surg (Br), 2006, 88(7): 909-913.
8.	梁景棋, 趙宏謀, 張言, 等. 踝上截骨結合關節牽開治療距骨傾斜角增大的內翻型踝關節骨性關節炎: 病例報告與文獻回顧. 足踝外科電子雜志, 2017, 4(3): 44-47.
9.	梁景棋, 張言, 溫曉東, 等. 內翻型踝關節炎踝上截骨聯合內側牽開與否比較. 中國矯形外科雜志, 2021, 29(17): 1537-1542.
10.	Liang JQ, Wang JH, Zhang Y, et al. Fibular osteotomy is helpful for talar reduction in the treatment of varus ankle osteoarthritis with supramalleolar osteotomy. J Orthop Surg Res, 2021, 16(1): 575. doi: 10.1186/s13018-021-02732-8.
11.	Zhou BF. Cooperative meta-analysis group of the working group on obesity in china. Predictive values of body mass index and waist circumference for risk factors of certain related diseases in Chinese adults-study on optimal cut-off points of body mass index and waist circumference in Chinese adults. Biomed Environ Sci, 2002, 15(1): 83-96.
12.	Kr?henbühl N, Zwicky L, Bolliger L, et al. Mid- to long-term results of supramalleolar osteotomy. Foot Ankle Int, 2017, 38(2): 124-132.
13.	Knupp M. The use of osteotomies in the treatment of asymmetric ankle joint arthritis. Foot Ankle Int, 2017, 38(2): 220-229.
14.	Kr?henbühl N, Akkaya M, Deforth M, et al. Extraarticular supramalleolar osteotomy in asymmetric varus ankle osteoarthritis. Foot Ankle Int, 2019, 40(8): 936-947.
15.	Ahn TK, Yi Y, Cho JH, et al. A cohort study of patients undergoing distal tibial osteotomy without fibular osteotomy for medial ankle arthritis with mortise widening. J Bone Joint Surg (Am), 2015, 97(5): 381-388.
16.	Kobayashi H, Kageyama Y, Shido Y. Treatment of varus ankle osteoarthritis and instability with a novel mortise-plasty osteotomy procedure. J Foot Ankle Surg, 2016, 55(1): 60-67.
17.	Lai L, Wang Y, Wu Y, et al. Outcomes of intermediate stage varus ankle arthritis treated by supramalleolar osteotomy. J Orthop Surg (Hong Kong), 2022, 30(3): 10225536221132769. doi: 10.1177/10225536221132769.
18.	Ayyaswamy B, Jain N, Limaye R. Functional and radiological medium term outcome following supramalleolar osteotomy for asymmetric ankle arthritis-A case series of 33 patients. J Orthop, 2020, 21: 500-506.

1. Horisberger M, Hintermann B, Valderrabano V. Alterations of plantar pressure distribution in posttraumatic end-stage ankle osteoarthritis. Clin Biomech (Bristol, Avon), 2009, 24(3): 303-307.
2. Haraguchi N, Ota K, Tsunoda N, et al. Weight-bearing-line analysis in supramalleolar osteotomy for varus-type osteoarthritis of the ankle. J Bone Joint Surg (Am), 2015, 97(4): 333-339.
3. Hintermann B, Ruiz R, Barg A. Novel double osteotomy technique of distal tibia for correction of asymmetric varus osteoarthritic ankle. Foot Ankle Int, 2017, 38(9): 970-981.
4. Hongmou Z, Xiaojun L, Yi L, et al. Supramalleolar osteotomy with or without fibular osteotomy for varus ankle arthritis. Foot Ankle Int, 2016, 37(9): 1001-1007.
5. Zhao HM, Liang XJ, Li Y, et al. Supramalleolar osteotomy with distraction arthroplasty in treatment of varus ankle osteoarthritis with large talar tilt angle: A case report and literature review. J Foot Ankle Surg, 2017, 56(5): 1125-1128.
6. Takakura Y, Tanaka Y, Kumai T, et al. Low tibial osteotomy for osteoarthritis of the ankle. Results of a new operation in 18 patients. J Bone Joint Surg (Br), 1995, 77(1): 50-54.
7. Tanaka Y, Takakura Y, Hayashi K, et al. Low tibial osteotomy for varus-type osteoarthritis of the ankle. J Bone Joint Surg (Br), 2006, 88(7): 909-913.
8. 梁景棋, 趙宏謀, 張言, 等. 踝上截骨結合關節牽開治療距骨傾斜角增大的內翻型踝關節骨性關節炎: 病例報告與文獻回顧. 足踝外科電子雜志, 2017, 4(3): 44-47.
9. 梁景棋, 張言, 溫曉東, 等. 內翻型踝關節炎踝上截骨聯合內側牽開與否比較. 中國矯形外科雜志, 2021, 29(17): 1537-1542.
10. Liang JQ, Wang JH, Zhang Y, et al. Fibular osteotomy is helpful for talar reduction in the treatment of varus ankle osteoarthritis with supramalleolar osteotomy. J Orthop Surg Res, 2021, 16(1): 575. doi: 10.1186/s13018-021-02732-8.
11. Zhou BF. Cooperative meta-analysis group of the working group on obesity in china. Predictive values of body mass index and waist circumference for risk factors of certain related diseases in Chinese adults-study on optimal cut-off points of body mass index and waist circumference in Chinese adults. Biomed Environ Sci, 2002, 15(1): 83-96.
12. Kr?henbühl N, Zwicky L, Bolliger L, et al. Mid- to long-term results of supramalleolar osteotomy. Foot Ankle Int, 2017, 38(2): 124-132.
13. Knupp M. The use of osteotomies in the treatment of asymmetric ankle joint arthritis. Foot Ankle Int, 2017, 38(2): 220-229.
14. Kr?henbühl N, Akkaya M, Deforth M, et al. Extraarticular supramalleolar osteotomy in asymmetric varus ankle osteoarthritis. Foot Ankle Int, 2019, 40(8): 936-947.
15. Ahn TK, Yi Y, Cho JH, et al. A cohort study of patients undergoing distal tibial osteotomy without fibular osteotomy for medial ankle arthritis with mortise widening. J Bone Joint Surg (Am), 2015, 97(5): 381-388.
16. Kobayashi H, Kageyama Y, Shido Y. Treatment of varus ankle osteoarthritis and instability with a novel mortise-plasty osteotomy procedure. J Foot Ankle Surg, 2016, 55(1): 60-67.
17. Lai L, Wang Y, Wu Y, et al. Outcomes of intermediate stage varus ankle arthritis treated by supramalleolar osteotomy. J Orthop Surg (Hong Kong), 2022, 30(3): 10225536221132769. doi: 10.1177/10225536221132769.
18. Ayyaswamy B, Jain N, Limaye R. Functional and radiological medium term outcome following supramalleolar osteotomy for asymmetric ankle arthritis-A case series of 33 patients. J Orthop, 2020, 21: 500-506.

Chinese Journal of Reparative and Reconstructive Surgery

Effectiveness and risk factors of supramalleolar osteotomy in treatment of varus-type ankle arthritis

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