SLR - May 2023 - Andrew Thomas Stuhr, PGY-1, DPM
Title: Outcomes of intermediate stage varus ankle arthritis treated by supramalleolar osteotomyReference: Lai L, Wang Y, Wu Y, Sun N, Li Y, Du H, Gong X. Outcomes of intermediate stage varus ankle arthritis treated by supramalleolar osteotomy. J Orthop Surg (Hong Kong). 2022 Sep-Dec;30(3)
Level of Evidence: 4
Reviewed By: Andrew Thomas Stuhr, PGY-1, DPM
Residency Program: Northern Colorado Podiatry Surgical Residency Program – Greeley, CO
Podiatric Relevance: Evidence for surgical intervention of ankle osteoarthritis (OA) in patients with early or end-stage arthritis is well documented. Early ankle OA often involves ankle debridement; while end-stage ankle OA usually involves ankle fusion or replacement. This article provides evidence for use of supramalleolar osteotomies in patients with intermediate stage varus ankle OA where other procedures may be inappropriate.
Clinical Question: What are the short to mid-term postoperative clinical outcomes are achieved with supramalleolar osteotomies for patients with intermediate stage varus ankle arthritis?
Methods: Retrospective analysis of 57 patients between 3/2018 and 12/2019 with intermediate stage varus ankle osteoarthritis treated with supramalleolar osteotomies. The Takakura classification system was used ( “intermediate ankle arthritis” = stage II/IIIa/IIIb). Patients underwent either a medial opening wedge osteotomy (30 stage IIIa, 1 stage II); lateral closing wedge osteotomy (12 stage II), or dome osteotomy (14 stage IIIb). Patients had pre and postoperative AP and lateral weightbearing x-rays to assess tibial lateral surface, tibial anterior surface, and talar tilt angles. Follow-ups were at 3, 6, and 12 months and then yearly after surgery. AOFAS and VAS scores were recorded at preoperative and last follow-up. Differences in the above indicators were then analyzed and compared.
Results: Preoperative and last follow-up AOFAS (64.2+/-14.6 and 84.1+/-9.7) and VAS (4.5+/-1.8 and 2.2+/-1.3) scores were statistically significant for all groups (<0.001 and 0.001, respectively). Preoperative and last follow-up TAS (80.5±6.7° and 92.4±5.5°), TLS (74.9±4.6° and 79.3±5.3°), and TT (5.2±64.1° and 3.7±3.4°) angles analyzed were statistically significant for TAS (p=<0.001) and TLS angles (p=<0.001) within all groups, but TT angles were significantly different for stage IIIb patients (p=.003) only.
Conclusions: The authors concluded that supramalleolar osteotomies achieved good short to mid-term clinical outcomes and radiographic correction. Supramalleolar osteotomies for intermediate varus ankle arthritis appear to be a viable alternate to inadequate or overly aggressive procedures, at least in the short to mid-term period. More studies are required, as the sample size is quite low but similar studies, as mentioned in the article, echoed the same conclusions for stage II/IIIa patients. However, there are mixed results in patients with stage IIIb ankle arthritis. Differentiating stage IIIb varus vs valgus ankle arthritis and comparing the clinical outcomes compared to alternative procedures for ankle arthritis may better elucidate supramalleolar osteotomy’s use for specific patient population. In summary, the article provides a different surgical option which may be advantageous to alternatives for intermediate varus ankle arthritis patients. Supramalleolar osteotomies are something I’ll consider going forward in practice.