Brachymetatarsia: A Classification for Surgical Treatment.

Brachymetatarsia is a congenital osseous and soft tissue deformity of a ray(s) of the foot. Because there is no particular consensus of methodology of lengthening for brachymetatarsia, the authors introduce a comprehensive anatomic classification and a surgical guide to treatment of each classification type. This classification combines the number of the metatarsal(s) affected and the letter(s) indicating the type of brachymetatarsia deformity (A = axial deficiency of the metatarsal, B = bowing of the metatarsal, C = congruency of metatarsal phalangeal joint). This study reviewed of 300 brachymetatarsals in 166 patients. Fifty of the 166 (30%) patients had bilateral brachymetatarsia. Of the 300 metatarsals with brachymetatarsia, 64 (21%) were first metatarsals, 22 (7%) were second metatarsals, 28 (9%) were third metatarsals, 12 (4%) were fifth metatarsals, and 174 (58%) were fourth metatarsals. Classification types that were found was a total of 165 (55%) type A, a total of 6 (2%) type B, a total of 72 (24%) type AB, a total of 39 (13%) type AC, and a total of 18 (6%) type ABC. A total of 16 (10%) male and 150 (90%) female patients were evaluated. The mean preoperative amount of shortening of the metatarsal was 15 mm (range, 4-20 mm), as determined by the preoperative metatarsal parabola deficiency, equating to 30% of the preoperative metatarsal length. Brachymetatarsia is a complex congenital deformity which until now has not been critically analyzed. This study outlines a comprehensive brachymetatarsia classification system which provides an accurate diagnosis of the deformity and offers a surgical treatment algorithm.

Evans Calcaneal Osteotomy: Assessment of Multiplanar Correction.

Flatfoot deformity consists of collapse of the medial arch, forefoot abduction, increased talonavicular uncoverage, and hindfoot valgus. Although numerous soft tissue and bony procedures have been proposed to correct each plane of deformity, there is a lack of objective data in the literature quantifying the amount of structural correction. The purpose of this study was to quantify the multiplanar deformity correction of the lateral column lengthening osteotomy (Evans) on hindfoot alignment through objective, reproducible, radiographic measurements. We retrospectively reviewed 45 Evans calcaneal osteotomy procedures in 24 female (53%) and 21 male (47%) feet performed on 40 patients (5 bilateral). The mean follow-up was 53 weeks (range, 32-116). The mean age at the time of surgery was 35 years (range, 11-73). Statistically significant improvement in radiographic alignment was found in the calcaneal inclination angle, tibial-calcaneal angle, tibial-calcaneal position, and the anteroposterior talo-first metatarsal angle (p < .0001 for all). Although a direct correlation between graft size and degree of angular correction was not observed, it should be noted the calcaneal graft size (mean, 11.8 mm) and the amount of hindfoot valgus correction (mean, 12.6°) appear to be clinically related. The results of this study support that the Evans calcaneal osteotomy corrects the hindfoot alignment in 3 planes as evidenced by our multiplanar radiographic measurements.

Coronal Hindfoot Alignment in Midfoot Charcot Neuroarthropathy.

Coronal plane hindfoot malalignment produces abnormal compensatory forces within the midfoot and forefoot. The primary aim of this study is to compare radiographic hindfoot alignment in patients with a midfoot Charcot event, and identify patterns associated with breakdown. A retrospective review of 43 patients (48 limbs) with midfoot Charcot neuroarthropathy were compared between the coronal hindfoot alignments and Charcot joint involvement. Coronal hindfoot alignment was classified as neutral (n = 15), valgus (n = 16), and varus (n = 17) utilizing the Saltzman hindfoot alignment radiograph. Charcot joint breakdown was classified as isolated tarsometatarsal joint (n = 8), combination of tarsometatarsal and naviculocuneiform joints (n = 22), and midtarsal joints including talonavicular and calcaneocuboid joints (n = 18). Patients exhibiting varus hindfoot alignment had 5.8 times greater risk of breakdown at the tarsometatarsal and naviculocuneiform joints (odds ratio 5.8, 95% confidence interval 1.7-22.9, p < .01). Hindfoot varus induces external rotation of the talus, resulting in compensation through the naviculocuneiform and tarsometatarsal joint, which correlates with our findings of a 6-fold increase in naviculocuneiform and tarsometatarsal joint collapse. Patients exhibiting valgus hindfoot alignment had 27 times greater risk of breakdown at the midtarsal joint (odds ratio 27.0; 95% confidence interval 5.6-207.0, p < .01). Hindfoot valgus induces internal rotation of the talonavicular joint, which correlates with our findings of a 27-fold increase in midtarsal joint breakdown. Varus and valgus hindfoot alignment are associated with different midfoot injury patterns, which may have implications in surgical management and allow for focused surveillance in neuropathic patients presenting with early-stage clinical findings consistent with Charcot neuroarthropathy.

Safety of Tibial Half Pins With Circular External Fixation for Foot and Ankle Reconstruction in Patients With Peripheral Neuropathy.

The primary aim of the study was to evaluate the rate of tibial fracture with half pin placement in conjunction with tensioned wires in Ilizarov static external fixator in patients with peripheral neuropathy. Concentric visualization through a rancho cube and careful identification of anterior, posterior, medial, and lateral borders of the tibia, the "perfect circle" technique was used to ensure avoidance of cortical breach. Bivariate analysis was performed comparing the rates of tibia fractures in those who did and did not employ the "perfect circle" technique for placement of tibial half pins; evaluating for demographics, rationale for external fixation use, and postoperative amputation and complication rates. Tibial stress fractures, and early removal of pin/wires from external fixator secondary to breakage both occurred at statistically significant higher rates in patients in which the "perfect circle" technique was not employed (p < .001 and p = .03 respectively). The overall rate of tibia stress fractures was 2.08% (2/96), 0% (0/85) when "perfect circle" technique was used, compared to 18.18% (2/11) when it was not used. This study demonstrates a substantially low rate of tibia stress fractures with half pin use, in contrast to prior literature and should provide foot and ankle surgeons confidence, particularly when appropriate placement is observed in this high-risk population.

Simultaneous Limb Lengthening With Ankle Fusion Using an Internal Lengthening Nail.

We reviewed 18 limbs in 17 patients who underwent ankle fusion with simultaneous tibial lengthening with a magnetic internal lengthening nail. All patients had preoperative limb length discrepancy (LLD) (mean 4.9 cm (2.6-7.6 cm)) with ankle deformity. The ankle was fused from medial or lateral approaches using screws/plate constructs placed adjacent to the retrograde Precise nail. Lengthening was carried out by a distal 1/3 tibial osteotomy. Clinical and radiographic measures were performed after a mean follow-up of 20 months (12-37 months). The mean amount of lengthening performed was 4 cm (1.8-7.2 cm). The final mean LLD was 1 cm (0.7-1.1 cm), which was statistically significant (p<0.01) as compared to preoperative. The foot was plantigrade in all cases. The mean foot rotation was 10° (5-15°) external, relative to the knee. At final follow-up all patients reported minimal to no pain, and all claimed to be walking more functionally than before surgery. Ankle fusion and limb lengthening was achieved in all cases. Combining both treatments by using an internal lengthening nail was very effective and avoided leaving patients with a dysfunctional LLD or of having a separate limb lengthening procedure. This is the first report of such a combined treatment of ankle fusion with internal tibial lengthening nail.

Realignment Midfoot Osteotomy: A Preoperative Planning Method and Intraoperative Surgical Technique.

Deformities of the midfoot are often treated with midfoot osteotomies. The goal of the midfoot osteotomy is to create a plantigrade forefoot to hindfoot relationship. Many different techniques are described for performing midfoot osteotomies. Our goal is to present an objective pre-operative planning method and an intra-operative technique for accurate multiplanar realignment and discuss our short-term results. We retrospectively reviewed 18 patients, 10 female (56%) and 8 male (44%), that underwent realignment midfoot osteotomies. The mean follow-up was 25 months (range, 4-120). The mean age at the time of surgery was 53 years (range, 21-76). Statistically significant improvement in radiographic alignment was found in the anteroposterior talo-first metatarsal angle (p = .002) and the mechanical axis deviation of the foot (p = .02). This study proved that our pre-operative and intra-operative planning technique provides accurate multiplanar radiographic realignment with good clinical results.

Avascular Necrosis of the First Metatarsal: A Case of Second Metatarsal Bone Transport with External Fixation.

Avascular necrosis (AVN) after bunion surgery is an unfortunate complication which can be devastating and painful. We present a case report of gradual medializing transport of the second metatarsal with external fixation to repair a large bone defect caused by AVN affecting >50% of the first metatarsal. The procedure was performed on a 49-year-old female who suffered AVN after failed bunion surgery. At 12-month follow up, first ray position and length were maintained. With respect to the second ray, there were no clinically significant issues. The second digit was mildly elevated but there was no frank instability of the toe or of the Lisfranc complex. The patient was pain free and had returned to her desired daily activities.

Ilizarov External Fixation for Correcting Complex Postpolio Foot and Ankle Deformity: A Case Study.

Given their severity and resultant loss of function, postpoliomyelitic foot and ankle deformities require a unique correction method. Correction with dynamic Ilizarov external fixation is one such modality, although it is technically demanding and requires precise preoperative planning. In our case study, a 40-year-old male with a severe postpoliomyelitic equinocavovarus right foot and ankle deformity was treated with gradual correction using dynamic, hinged Ilizarov external fixation. The external fixation was in place for a total of 103 days, with gradual correction performed in 2 successive steps, achieving a functional, plantigrade foot. We maintained this position in a short leg cast for 30 days, followed by bracing and physiotherapy for 6 months. More than 2 years after the index surgery, the patient had achieved a painless and plantigrade foot, allowing for functional ambulation. This method does not require osteotomies, ankle arthrodesis, or tendon transfer.

Intramedullary Metatarsal Fixation for Treatment of Delayed Regenerate Bone in Lengthening of Brachymetatarsia.

Delayed regenerate healing after distraction osteogenesis can be a challenging problem for patients and surgeons alike. In the present study, we retrospectively reviewed the data from a cohort of patients with delayed regenerate healing during gradual lengthening treatment of brachymetatarsia. Additionally, we present a novel technique developed by 1 of us (B.M.L.) for the management of delayed regenerate healing. We hypothesized that application of intramedullary metatarsal fixation would safely and effectively promote healing of poor quality, atrophic regenerate during bone lengthening in brachymetatarsia correction. We formulated a study to retrospectively review the data from a cohort of patients with delayed regenerate healing after gradual lengthening for brachymetatarsia. All patients underwent temporary placement of intramedullary fixation after identification of delayed regenerate healing. Patient-related variables and objective measurements were assessed. We identified 10 patients with 13 metatarsals treated with intramedullary fixation for delayed regenerate healing. All 10 patients were female, with 6 (46.2%) right metatarsals and 7 (53.8%) left metatarsals treated. No complications developed with the use of this technique. All subjects progressed to successful consolidation of the regenerate bone at a mean of 44.5 ± 30.2 days after placement of intramedullary metatarsal fixation. No regenerate fracture or reoperations were noted. In conclusion, intramedullary metatarsal fixation is a safe and effective method for managing delayed regenerate healing encountered during distraction osteogenesis correction of brachymetatarsia.

Modified Percutaneous Hallux Abductovalgus Correction.

Percutaneous surgical techniques and minimally invasive procedures in foot and ankle surgery are gaining interest for both patients and surgeons. Percutaneous surgery is defined by a soft tissue or osseous procedure performed through the smallest possible incision without direct visualization of the underlying target structures. Percutaneous surgery has many potential advantages, including quicker operative times, multiplanar osteotomy correction, smaller incisions, decreased scarring, lower complication rates, and faster recovery times. The potential disadvantages include the need for specific equipment, that it cannot be used for large deformities, and that it requires an extensive learning curve. A commonly attempted percutaneous procedure is first metatarsal osteotomy for correction of hallux abductovalgus or bunion. We present our preoperative planning and intraoperative techniques for percutaneous hallux abductovalgus correction.

Normal Foot and Ankle Radiographic Angles, Measurements, and Reference Points.

The limb deformity-based principles originate from a standard set of lower extremity radiographic angles and reference points. Objective radiographic measures are the building blocks for surgical planning. Critical preoperative planning and intraoperative and postoperative evaluation of radiographs are essential for proper deformity planning and correction of all foot and ankle cases. A total of 33 angles and reference points were measured on 24 healthy feet. The radiographic measurements were performed on standard weightbearing anteroposterior, lateral, and axial views of the right foot. A total of 4 measurements were made from the axial view, 12 from the lateral view, and 17 from the anteroposterior view. All angles were measured by both senior authors twice, independent of each other. The radiographic angles and measurements presented in the present study demonstrate a comprehensive and useful set of standard angles, measures, and reference points that can be used in clinical and perioperative evaluation of the foot and ankle. The standard radiographic measures presented in the present study provide the foundation for understanding the osseous foot and ankle position in a normal population.

Preoperative Planning and Intraoperative Technique for Accurate Translation of a Distal First Metatarsal Osteotomy.

We used preoperative radiographic and intraoperative anatomic measurements to predict and achieve, respectively, the precise amount of capital fragment lateral translation required to restore anatomic balance to the first metatarsophalangeal joint. Correlation was used to relate the amount of capital fragment translation and operative reduction of the first intermetatarsal angle (IMA), hallux abductus angle (HAA), tibial sesamoid position (TSP), metatarsus adductus angle, and first metatarsal length. The mean capital fragment lateral translation was 5.54 ± 1.64 mm, and the mean radiographic reductions included a first IMA of 5.04° ± 2.85°, an HAA of 9.39° ± 8.38°, and a TSP of 1.38 ± 0.9. These changes were statistically (p < .001) and clinically (≥32.55%) significant. The mean reduction of the metatarsus adductus angle was 0.66° ± 4.44° and that for the first metatarsal length was 0.33 ± 7.27 mm, and neither of these were statistically (p = .5876 and 0.1247, respectively) or clinically (≤3.5%) significant. Pairwise correlations between the amount of lateral translation of the capital fragment and the first IMA, HAA, and TSP values were moderately positive and statistically significant (r = 0.4412, p = .0166; r = 0.5391, p = .0025; and r = 0.3729, p = .0463; respectively). In contrast, the correlation with metatarsus adductus and the first metatarsal shortening were weak and not statistically significant (r = 0.2296, p = .2308 and r = -0.2394, p = .2109, respectively). The results of our study indicate that predicted preoperative and executed intraoperative lateral translation of the capital fragment correlates with statistically and clinically significant reductions in the first IMA, HAA, and TSP.

Realignment Subtalar Joint Arthrodesis.

Subtalar joint arthrodesis is a commonly performed procedure for the correction of hindfoot deformity and/or the relief of pain related to osteoarthritis. The purpose of the present study was to provide preoperative and intraoperative objective radiographic parameters to improve the accuracy and long-term success of realignment arthrodesis of the subtalar joint. We retrospectively reviewed the data from 16 patients, 11 male (57.9%) and 8 female (42.1%) feet, who had undergone realignment subtalar joint arthrodesis. A total of 19 fusions were performed in 9 (47.4%) right and 10 (52.6%) left feet, with a mean follow-up period of 2 (range 1 to 4.8) years. The mean age at surgery was 54.5 (range 14 to 77) years. Statistically significant improvement in radiographic alignment was found in the anteroposterior talo-first metatarsal angle (p = .002), lateral talo-first metatarsal angle (p < .001), tibial-calcaneal angle (p < .001), and tibial-calcaneal distance (p < .001). A positive correlation was observed between the tibial-calcaneal angle and tibial-calcaneal distance (r = 0.825, p < .001). The statistically significant improvement in tibial-calcaneal alignment, in both angulation and distance, support our conclusions that proper realignment of the calcaneus to vertical and central under the tibia will lead to short-term success and, likely, long-term success of subtalar joint arthrodesis.

Effect of Pedal Deformity on Gait in a Patient With Total Knee Arthroplasty.

The authors present the case of an 81-year-old man who, despite an anatomically aligned total knee arthroplasty, continued to have knee pain. The patient's ipsilateral rigid flatfoot caused by an earlier partial pedal amputation resulted in a valgus moment during gait, thus creating clinical symptoms in the total knee arthroplasty. Because of the deformity and scarring within the flatfoot, this valgus deformity was corrected through a varus distal femoral osteotomy. The result was normalization of the mechanical axis of the lower limb and a pain-free total knee arthroplasty with an excellent clinical outcome. This case shows the importance of comprehensive lower-extremity clinical and radiographic examination as well as gait analysis to understand the biomechanical effect on total knee arthroplasty. Recognition of pedal deformities and lower limb malalignment is paramount for achieving optimal outcomes and long-term success of total knee arthroplasty. The authors show that a rigid or nonflexible pedal deformity can have negative biomechanical effects on total knee arthroplasty.

Distraction osteogenesis for complex foot deformities: Gigli saw midfoot osteotomy with external fixation.

Open midfoot wedge osteotomy correction can cause neurovascular compromise, requires extensive exposure, sacrifices normal joints, and shortens the foot. We used a minimally invasive technique to treat complex foot deformities by combining percutaneous Gigli saw midfoot osteotomy, circular external fixation, and acute, gradual, or gradual with acute manipulation correction. The medical records of 23 patients (26 feet) with complex foot deformities (congenital, 18 feet; neuromuscular, 4 feet; post-traumatic, 3 feet; malunion, 1 foot) who had undergone treatment within an 18-year period (1990 through 2007) were retrospectively reviewed. We also performed the procedure on 10 cadaveric limbs to determine whether anatomic structures were at risk. Correction was achieved in all feet. The mean duration of external fixation treatment was 4.2 (range 3 to 7) months. The mean follow-up duration was 4.7 (range 2 to 18) years. A significant difference was observed in the pre- and postoperative, lateral view, talar-first metatarsal angle (p = .001). Minor complications (4 feet) consisted of bony exostoses. Major complications included recurrent deformity in 3 feet and sural nerve entrapment in 1 foot. Two patients had mild and one moderate foot pain. Three patients had impaired gait function; the remaining patients had functional gait. The mean interval until wearing regular shoes after external fixation removal was 2.3 (range 1 to 4) months. All but 1 of the patients were satisfied with the final results. We observed no cadaveric neurovascular injury. Our results have shown that percutaneous Gigli saw midfoot osteotomy can be performed without neurovascular injury and is capable of successfully correcting complex foot deformities.

Immediate weightbearing after Lapidus arthrodesis with external fixation.

A common surgical treatment of severe hallux abductovalgus deformity with coincident first ray hypermobility is metatarsal-cuneiform fusion or Lapidus procedure. The aim of the present study was to illustrate a reliable and novel method of fixation for Lapidus fusion using an external fixation device through a retrospective cohort investigation of consecutive patients. Twenty Lapidus fusions were performed in 19 patients, including 17 females (89.47%) and 2 males (10.53%). The mean age at surgery was 41 (range 20 to 64) years. The patients were evaluated clinically and radiographically pre- and postoperatively. The mean duration in the fixator was 12 (range 3 to 34) weeks. The mean interval to radiographic union was 9.2 (range 4.7 to 30.7) weeks in 18 of 20 feet (90%) and 2 (10%) were designated as nonunion. The mean follow-up period was 37 (range 5.6 to 211.1) weeks. The most common complication was pin tract infection in 5 patients (6 feet) and was treated with oral antibiotics; only 1 foot required early hardware removal. According to the visual analog scale, the mean patient pain score decreased significantly from 8.2 ± 2.7 to 0.83 ± 0.98 postoperatively (p < .001). Our results highlight that immediate weightbearing after Lapidus fusion with external fixation is a viable treatment option for the correction of severe hallux abductovalgus with associated hypermobility.

Digital planning for foot and ankle deformity correction: Evans osteotomy.

Preoperative planning is commonly performed for many foot and ankle procedures. The purpose of the present study was to prospectively determine the preoperative digital planning accuracy of predicting the calcaneal graft size used during the "Evans" calcaneal osteotomy. Preoperative digital deformity correction planning, using a standard planning method (TraumaCad(®) software), was performed on 10 feet scheduled to undergo an Evans procedure. Of the 10 patients, 6 were female and 4 were male, with an average age of 43 ± 22 years. Digital planning was used to predict the Evans graft size. The surgeon was unaware of the predicted graft size, which was then compared with the actual graft size inserted during the procedure. In addition, the pre- and postoperative radiographic angles were recorded and compared (anteroposterior view, talo-first metatarsal angle, calcaneocuboid abduction; lateral view, calcaneal inclination angle; and axial view, tibial-calcaneal angle). The average preoperative talo-first metatarsal angle, calcaneocuboid angle, calcaneal inclination angle, and tibial-calcaneal angle measured 21° ± 9.6°, 28.3° ± 9.0°, 13.8° ± 5.7°, and 15.3° ± 8.2°, respectively. The preoperative tibial-calcaneal position was 2.8 ± 1.2 mm. The radiographic weightbearing angles measured at an average follow-up of 7.4 (range 6 to 12) months improved to 6.3° ± 7.4° (p = .0015), 12.3° ± 6.1° (p < .001), 21.3° ± 7.7° (p = .0122), and 2.2° ± 3.6° (p = .0019) for the talo-first metatarsal, calcaneocuboid abduction, calcaneal inclination, and tibial-calcaneal angles, respectively. The final tibial-calcaneal position measured 1.4 ± 0.7 mm (p < .001). The preoperative Evans graft measurement (11.8 ± 2.6 mm) compared with the actual graft (12.2 ± 1.3 mm) placed was within 0.4 ± 1.8 mm (p = .51). Preoperative digital planning for Evans calcaneal osteotomy has been shown to be a valuable tool for predicting the surgical graft size for accurate pedal realignment.

Clinical characteristics of early-stage osteonecrosis of the ankle and treatment outcomes.

BACKGROUND: The purposes of this study were to describe the clinical manifestations of osteonecrosis involving the distal tibia and talus, to identify risk factors associated with the disease, and to evaluate the efficacy of percutaneous drilling for the treatment of ankles with early-stage symptomatic osteonecrosis. METHODS: One hundred and one ankles in seventy-three patients with symptomatic osteonecrosis of the talus and/or distal tibia treated with percutaneous drilling were identified. There were eighty-one ankles in fifty-nine patients treated only at our institution and twenty ankles in fourteen patients with a failed prior core decompression at outside institutions. The parameters evaluated included demographics, disease characteristics, clinical outcomes including the American Orthopaedic Foot & Ankle Society score, Short-Form-36 scores, University of California Los Angeles activity scores, and visual analog scale pain scores, and radiographic outcomes at a mean follow-up duration of five years (range, two to nine years). RESULTS: Eighty-five ankles had isolated talus osteonecrosis, eleven ankles had involvement of the distal tibia and talus, and five ankles had isolated distal tibial disease. Twenty-nine patients (40%) had initially presented with symptomatic osteonecrosis of another joint, most commonly the knee (37%), the hip (29%), and the shoulder (25%). The most common identifiable risk factors included chronic corticosteroid use (49.3%), alcohol abuse (35.6%), tobacco use (29%), and hypertension (20.5%). Overall, 83% of ankles did not demonstrate further disease progression after the procedure. There were significant improvements (p < 0.05) in clinical and patient-reported outcomes after surgical treatment. The presence of human immunodeficiency virus and sickle cell disease was associated with a higher odds ratio of disease progression to joint collapse. CONCLUSIONS: Osteonecrosis of the distal tibia and talus was usually part of multifocal disease, and concurrent knee osteonecrosis was more common than hip osteonecrosis. The results of the present study suggest that early-stage ankle osteonecrosis can be treated successfully with percutaneous drilling.

Percutaneous Drilling for Early-Stage Osteonecrosis About the Ankle.

INTRODUCTION: The mid-term clinical, patient-reported, and radiographic outcomes of percutaneous drilling to treat early-stage osteonecrosis (without joint collapse) of the distal part of the tibia or of the talus are promising. STEP 1 PREOPERATIVE PLANNING FOR A LATERAL TALAR LESION: Obtain anteroposterior and lateral ankle radiographs as well as magnetic resonance imaging (MRI) studies of the ankle to evaluate the stage of the osteonecrotic disease. STEP 2 PERCUTANEOUS PIN INSERTION LATERAL TALAR LESION: Insert a 1.8-mm Steinmann pin or Ilizarov wire percutaneously under biplanar fluoroscopic visualization. STEP 3 PERCUTANEOUS DRILLING: Make one, two, or three passes with a 3.2-mm cannulated drill bit over the pin into the lesion(s). STEP 4 BACKFILLING THE BONE TUNNEL OPTIONAL: Infiltrate the defect with demineralized bone matrix to backfill the drill track and the deep necrotic bone defect. STEP 5 POSTOPERATIVE MANAGEMENT: The patient bears weight as tolerated in a removable short leg rigid boot for the first four weeks and avoids high-impact activities for at least ten months. RESULTS: In our study, there were significant improvements in the mean American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score (p = 0.001), University of California Los Angeles (UCLA) activity score (p = 0.025), and visual analog scale (VAS) pain score (p = 0.001) at a mean of five years (range, two to nine years) postoperatively.IndicationsContraindicationsPitfalls & Challenges.

Supramalleolar osteotomy for realignment of the ankle joint.

Ankle replacement systems have not been as reliable as hip replacements in providing long-term relief of pain, increased motion, and return to full activity. Supramalleolar Osteotomy is an extraarticular procedure that realigns the mechanical axis, thereby restoring ankle function. The literature discussing knee arthritis has shown that realignment osteotomies of the tibia improve function and prolong total knee replacement surgery. The success of the procedure is predicated on understanding the patient's clinical and radiographic presentation and proper preoperative assessment and planning.