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21 (); 500-506
doi:
10.1016/j.jor.2020.08.038

Functional and radiological medium term outcome following supramalleolar osteotomy for asymmetric ankle arthritis- A case series of 33 patients

, ,
North Tees and Hartlepool NHS Trust.Stockton on Tees, United Kingdom

∗Corresponding author: Brijesh Ayyaswamy. brijeshayyaswami@gmail.com

Received: , Accepted: ,
Professor P K Surendran Memorial Education Foundation
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

Ankle arthritis is one of the most disabling and painful conditions. Up to 37.5% of ankle arthritis presents as asymmetric arthritis with ankle malalignment. Supramalleolar osteotomy is a joint sparing operation, which aims to realign the ankle joint that will prevent progression of arthritis and relieve patient's symptoms.

The aim of this study is to analyse the medium term functional and radiographic outcomes of patients who underwent supramalleolar osteotomy for asymmetric ankle arthritis.

This is a retrospective outcome study of medium term outcome for 33 patients who underwent Supramalleolar osteotomy for asymmetric ankle arthritis by a single surgeon. We assessed the functional outcome of the patients with AOFAS and VAS score. The radiological parameters measured were Tibial articular surface ankle (TAS), Hind foot alignment angle (HFA) and Talar tilt angle (TT). We used the paired Student's t-test to compare the preoperative and postoperative radiographic measurements, AOFAS and VAS scores. We set the significance level at P < 0.05.

We had 21 patients who underwent lateral closing wedge osteotomy for varus deformity and 12 patients who underwent medial closing wedge osteotomy for valgus deformity. The mean followup was 72 months [29–73]. The mean AOFAS score significantly improved by 44.82 ± 7.97 (p < 0.0001). The VAS score significantly improved by 5.06 ± 1.41 (p < 0.0001). All the radiological parameters showed statistically significant improvement. All osteotomy united by 8–10 weeks. We had one case of late deep wound infection, which settled down with by metalwork removal. The arthritis progressed in three cases, two patients had fusion and one patient had ankle replacement. We had 90.9% survival rate for our osteotomy at 6 years.

Supramalleolar osteotomy is an excellent option for patients with asymmetric ankle arthritis with good functional and radiological outcome and good medium term survival rate.

Abstract

Highlights

•Asymmetric ankle arthritis can occur secondary to ankle joint malalignment.•Supramalleolar osteotomy gives good medium to long term results in asymmetric ankle arthritis.•Supramalleolar osteotomy has shown to improve functional outcomes, improve joint alignment.•Our study shows more than 90% survival of osteotomy at 72 months with few complications.

Keywords

Deformity
Arthritis
Osteotomy
Outcomes
Complications
Failure
1

1 Introduction

Osteoarthritis (OA) of the ankle joint is the degeneration of articular cartilage and is often preceded by trauma to the ankle joint.1,2 It is a condition that could cause significant pain and functional disturbances and it disables over 10% of people who are older than 60 years. A significant proportion of all patients with end-stage ankle OA have a post-traumatic aetiology.3–5 There are other causes of ankle arthritis, which includes primary osteoarthritis, infection, talar osteonecrosis and Charcot neuropathy.6

Treatment options can be joint sacrificing or joint preserving. Joint-sacrificing options include ankle arthrodesis7–9 and total ankle arthroplasty.10–13 Ankle joint arthrodesis is associated with functional restriction, gait abnormalities and the development of secondary degenerative changes in the adjacent joints.10–18 Joint preserving options include arthroscopic debridement,19,20 shell allograft procedures21,22 and distraction arthroplasty,23,24 but these options do not tackle the underlying deformity and eccentric loading, particularly in patients with altered mechanics.25–27

Supramalleolar osteotomy is another established joint-preserving treatment option in patients with ma malalignment and eccentric cartilage loss. It also addresses deformity and eccentric loading in bio-mechanically disturbed ankle joint.25–27 Previous studies showed good to excellent outcomes after supramalleolar osteotomy. The studies by Pagenstert et al.,28 Knupp et al. 27, Cheng et al.,29 Takakura et al.,30 and Stamatis et al.25 has shown good to excellent functional outcomes following supramalleolar osteotomy

1.1

1.1 Biomechanics

A cadaveric study by Knupp et al.31 suggested that a varus deformity of the ankle resulted in an overload of the medial part of the tibio talar joint, and a valgus deformity shifted the forces to the lateral side of the joint. The laxity of the supporting ligaments around the ankle could lead to abnormal load distribution in the ankle leading to instability. The study also suggested that these deformities affect force and load transfer in the coronal and the sagittal planes. And therefore, when planning deformity corrections in the supramalleolar area, the bi-planar pattern of changes in load transfer must be taken into consideration.

The aim of this study is to analyse the functional and radiographic outcomes of patients who underwent supramalleolar osteotomy for asymmetric ankle arthritis. The secondary outcomes include assessing failure and complication rates.

2

2 Materials and Methods

This study is a single centre, ethically approved retrospective outcome study of supramalleolar osteotomy by a single surgeon at NHS hospitals, United Kingdom between 2008 and 2015. Our study included 33 patients who underwent supramalleolar osteotomy for patients with asymmetric ankle arthritis. These patients had either persistent or worsening of symptoms after non-operative treatment for ankle arthritis, which include painkillers, intra-articular injections and ankle boots. None of the patients had any major co-morbidities and all of the patients were ASA 2 or less.

2.1

2.1 Inclusion and exclusion criteria

Our inclusion criteria for this procedure were patients with isolated coronal plane deformities with clinical symptoms of severe walking pain and limitation of daily activities, and asymmetric ankle arthritis with preservation of over of healthy articular cartilage on unaffected are of the ankle during arthroscopic assessment.5 We explained all the options including arthrodesis, replacement and osteotomy and final surgical option was based on patients decision.

We excluded patients with sagittal plane deformities, end stage global ankle arthritis, infections, ankles with concentric arthritis or inflammatory arthritis and patients with neuropathic disorder or vascular insufficiency, established osteoporosis and BMI >35.

2.2

2.2 Clinical evaluation

All patients included underwent a standardised process of care from the time of assessment to diagnosis and throughout postoperative follow up and long-term care. Pre-operative planning included detailed history and examination of the lower limb to rule out any other proximal or distal deformities. We used AOFAS and VAS pain scale scoring systems for preoperative and postoperative functional assessment. We arbitrarily created two groups as per Colin et al.32 based on the AOFAS scores: those with AOFAS scores below 65 points (poor results) and above 65 (good and excellent results). We recorded all associated procedures performed along with osteotomy. We recorded all complications. We defined failure as the patient requiring either arthrodesis or ankle replacement for persistent or recurrent symptoms following the index supramalleolar osteotomy.

2.3

2.3 Radiological assessment

All patients had pre-operative weight bearing X-rays of both ankles, standing weight-bearing radiographs to rule out any abnormalities of the distal tibia and Saltzman view. Two surgeons measured the preoperative and follow-up radiographs to assess the radiological parameters used in this study.

Tibial articular surface angle [TAS] and Hind foot alignment angle [HFA] assessed the coronal plane deformities. TAS is angle between intersection of mechanical axis of tibia and articular surface of distal tibia on medial side. The normal angle is 890 32 [Fig. 1a]. The HFA angle is drawn between two lines, one line defining the hind foot alignment angle is drawn through the most distal point of the calcaneus resting on the floor and the point at the intersection of the tangent to the talar dome with the axis of the tibia. The other line defining the angle is the tibial axis. The normal mean value is between 20 and 60 33 [Fig. 1b]. Talar tilt angle calculated the tibio talar joint congruence [TT]. It is normally less than 40 32 [Fig. 1a]. The Tibial Lateral Surface (TLS) angle, used to measure the sagittal plane deformities is formed by the mechanical axis of the tibia and the line passing through the ends of the tibial articular surface in a lateral view. It is normally 810 32◦ These measurements were used to define the anatomical deformity and type of supramalleolar osteotomy. To calculate and determine the size of the wedge to be inserted or removed, Warnock and colleagues [19] confirmed accuracy using the mathematical formula tanα = H/W, where α is the angle to be corrected, H is the wedge height in millimetres, and W is the tibial width in millimetres.33 An overcorrection of 2°–5° is recommended. The CORA of the supramalleolar deformity is noted from the radiographs and osteotomy performed at the CORA. The aim was to correct the TAS and HFA to normal values.

1a- Radiographs showing Tibial articular surface angle (TAS) and Talar Tilt angle (TT). 1b- Radiographs showing Hindfoot alignment angle (HFA).
Fig. 1 1a- Radiographs showing Tibial articular surface angle (TAS) and Talar Tilt angle (TT). 1b- Radiographs showing Hindfoot alignment angle (HFA).
2.4

2.4 Surgical technique

All our osteotomies are done under general anaesthesia as part of day case procedure with enhanced recovery. The procedure starts off with ankle arthroscopy using standard non-invasive distraction technique. We used 4 mm arthroscope to inspect the cartilage and probe to make sure that there is good healthy cartilage in unaffected compartment of the ankle, Any osteophytes was shaved off. After arthroscopy the distractor is removed. We treat the valgus ankle with medial closing wedge osteotomy through a medial incision over tibia and then placed a separate incision on lateral side to osteotomise the fibula. The fibular is osteotomised and realigned as per the requirement in individual cases. Once we confirm the satisfactory alignment of the ankle joint is achieved by image intensifier and then we stabilised the osteotomy using Tibiaxys (Integra Life Sciences USA) plate on the tibia and standard fibula fixation plate using small fragment plate and screws. For varus angle we performed a lateral closing wedge osteotomy through anterolateral approach to tibia. The fibula is osteotomised in selective cases through a separate lateral incision. Fibula is shortened as required [Fig. 2]. In addition to bony procedures, ligament repair was done on medial or lateral side after doing and EUA once osteotomy was fixed. The wound is closed routinely using nylon skin sutures, and we applied a below knee plaster back slab.

2a and 2b- Intraoperative photographs showing the k wire inserted before osteotomy. 2b- The wedge is removed and osteotomy closed.
Fig. 2 2a and 2b- Intraoperative photographs showing the k wire inserted before osteotomy. 2b- The wedge is removed and osteotomy closed.
2.5

2.5 Postoperative protocol

Our patients underwent a standardised post-operative management plan, which involved a non-weight bearing below-knee cast for six weeks. It follows another four weeks in a boot with weight bearing as tolerated and we begin physiotherapy at this point. All patients received six weeks of venous thromboembolism prophylaxis. They all had regular follow up at 3, 6, 12, 18 and every 24 months with check radiographs for degree of correction and union.

2.6

2.6 Statistical analysis

We performed the statistical analysis using SSPS for windows v.24.0 (SSPS IBM, Armonk, New York, USA) software. We mention descriptive statistics as mean and standard deviation. The sample size was calculated using the mean normal TAS angle with an alpha error of 0.05. The minimum sample was determined to be 31 and we had 33 patients in our study. We used the paired Student's t-test to compare the preoperative and postoperative radiographic measurements, AOFAS and VAS scores. We set the significance level at P < 0.05.

3

3 Results

3.1

3.1 Population and procedure details

Out of 33 patients who underwent supramalleolar osteotomy for asymmetric ankle osteoarthritis, 21 patients had lateral closing wedge osteotomy for varus deformity and 12 patients had medial closing wedge osteotomy for valgus deformity. The average age of the patients included in the study was 57 years. There were 25 males and 8 females. The mean follow up for the patients was 72 months. The additional procedures included 21 patients with Modified Brostrom Gould procedure for lateral ligament reconstruction, two patients with deltoid ligament reconstruction and one had anterior arthroscopic cheilectomy ((Table 1).

Table 1 Table showing demographics and procedure details.
Number of patients 33
Male: Female 25:8
Deformity 21 varus deformity and 12 valgus deformity
Age Mean - 57 years, Range (29–73 months)
Follow up Mean 72 months, Range (60–92 months)
Osteotomy 21 Lateral closing wedge and 12 medial closing wedge osteotomy
Additional procedures 21 patients had Modified Brostrom Gould lateral ligament Repair, two deltoid ligament repair, one arthroscopic cheilectomy.
3.2

3.2 Time to union

The mean duration for radiological union was 8.6 weeks (8–10 weeks). There were no cases of nonunion or delayed unions in our study group.

3.3

3.3 Functional outcomes

The AOFAS score significantly improved by 44.82 points from a preoperative mean of 33.85 [15–46] to a postoperative mean of 78.67 [45–92] (p < 0.0001). The VAS score significantly improved by 5.06 cm from a preoperative mean of 8.42 cm [7−10] to a post-operative mean of 3.36 cm [1–6] (p < 0.0001) (Table 2). According to Colin et al.‘s 32 criteria of classifying the outcomes as per the AOFAS score, we had 87% good to excellent results at 6 years following the osteotomy.

Table 2 Table showing the preoperative and postoperative mean, standard deviation, mean of the difference, 95% confidence intervals and p value of Functional and Radiological outcome.Pre operative and post operative functional score and radiological parameters.
Scores Preoperative Postoperative Difference
Mean SD Min-Max Mean SD Mini-Max Mean SD 95% CI P
AOFAS 33.8 6.22 [15–46] 78.67 8.18 [45–92] 44.82 7.97 47.65–41.99 <0.0001
VAS 8.42 87 [7−10] 3.36 1.27 [1–6] 5.06 1.41 4.56–5.56 <0.0001
Varus deformity
TAS 82.6 2.67 [78.3–87.1] 90.48 1.36 [87–93] 7.89 2.67 6.66–9.08 <0.0001
TT 8 1.95 [4.8–13.5] 1.95 0.87 [0.4–3.9] 6.06 1.58 5.34–6.77 <0.0001
HFA 12.32 2.9 [8.5–18] 3.56 0.99 [1.9–5.6] 8.77 2.61 7.58–9.96 <0.0001
Valgus deformity
TAS 98.03 2.07 [100.5–94.6] 91.34 0.66 [90.3–92.5] 6.69 1.71 5.6–7.78 <0.0001
TT 5.74 1.43 [3.9–8.3] 1.41 0.40 [0.8–2.1] 4.3 1.43 3.41–5.23 <0.0001
HFA 11.5 1.97 [8.8–15] 3.68 0.78 [2.2.-4.8] 7.81 2.12 6.47–9.16 <0.0001
3.4

3.4 Radiological outcomes

3.4.1

3.4.1 Varus deformity

The TAS angle significantly improved by 7.89° from a preoperative mean of 82.6° [78.3–87.1] to a post-operative mean of 90.48° [87–93] (p < 0.001). The TT angle significantly improved by 6.06° from a mean of 8° [4.8–13.5] preoperatively to a post-operative mean of 1.95° [0.4–3.9] (p < 0.0001) [Fig. 3]. The HFA angle improved significantly by 8.77° from a preoperative mean of 12.32° [8.5–18] to post-operative mean of 3.56° [1.9–5.6] (p < 0.0001) (Table 2).

3a and 3b- Preoperative radiographs showing arthritis with varus malalignment. 3c and 3d- Postoperative radiographs showing correction of varus malalignment.
Fig. 3 3a and 3b- Preoperative radiographs showing arthritis with varus malalignment. 3c and 3d- Postoperative radiographs showing correction of varus malalignment.
3.4.2

3.4.2 Valgus deformity

The TAS angle significantly improved by 6.69° from preoperative mean of 98.03° [100.5–94.6] to a postoperative mean of 91.34° [90.3–92.5] (p < 0.0001). The TT angle significantly improved by 4.3° from a mean of 5.74° [3.9–8.3] preoperatively to a post-operative mean of 1.41° [0.8–2.1] (p < 0.001) [Fig. 4]. The HFA angle improved significantly by 7.81° from a preoperative mean of 11.5° [8.8–15] to a postoperative mean of 3.68° [2.2–4.8] (p < 0.0001) (Table 2).

4a and 4b- Preoperative radiographs showing arthritis with valgus malalignment. 4c and 4d- Postoperative radiographs showing correction of valgus malalignment.
Fig. 4 4a and 4b- Preoperative radiographs showing arthritis with valgus malalignment. 4c and 4d- Postoperative radiographs showing correction of valgus malalignment.
3.5

3.5 Complication

One patient had a late wound infection after 12 months, which needed washout and needed metalwork removal at 14 months, as infection did not settle with washout alone. The infection settled after removing the metalwork and did not have any further problem.

3.6

3.6 Failure

Three patients had persistent or worsening of their symptoms and radiological deterioration in arthritis. One patient underwent ankle arthroplasty at 13 months and two patients underwent arthroscopic ankle fusion at 18 months. Their pain settled, and they did not have any further symptoms [Fig. 5]. We classified these three patients as failures. At a mean followup of 6 years our success rate of supramalleolar osteotomy is 90.9% patients.

5 a and 5b- Intraoperative and 6 months Postoperative radiographs showing correction of varus malalignment of the ankle joint with asymmetric arthritis. 5c and 5d- Postoperative radiographs at 14 months showing recurrence of deformity with progression of arthritis and subsequent arthrodesis using two cannulated screws.
Fig. 5 5 a and 5b- Intraoperative and 6 months Postoperative radiographs showing correction of varus malalignment of the ankle joint with asymmetric arthritis. 5c and 5d- Postoperative radiographs at 14 months showing recurrence of deformity with progression of arthritis and subsequent arthrodesis using two cannulated screws.
4

4 Discussion

Our study shows that supramalleolar osteotomy is a good joint salvage option for patients with asymmetric ankle arthritis. Our patients showed significant improvement in AOFAS score by 44.82 points, VAS score by 5.06 cm and significant improvement in radiological parameters with low failure rate and complication rate.

Ankle osteoarthritis is one of most common joint disease and is a significant source of pain for middle age and elderly people throughout the world. Joint sacrificing procedures such as ankle arthroplasty34,35 or joint arthrodesis10–18 has a lot of disadvantages and has potential complications with need for revision, limitation of movements and adjacent joint arthritis. According to Wang et al.36 who analysed radiographs of 226 patients, 27.5% had supramalleolar varus deformity, 8.2% had supramalleolar valgus deformity, and only 64.4% were within 2 standard deviations of the normal population. At the infra malleolar level, 21.9% had varus deformity, 18.9% had valgus deformity, and only 59.2% had infra malleolar alignment within 2 standard deviations of the normal population. In our study, the majority of the patients with asymmetric arthritis had varus deformity.

A realignment osteotomy is based on the principle that the weight bearing can be realigned to delay the progression of arthritis and improve symptoms 22–24. A series published by Pagenstert et al.31 reported a good outcome in 35 patients who underwent supramalleolar osteotomies, with total ankle arthroplasty or ankle arthrodesis successfully avoided in 91% of patients at 5 years. Knupp et al. 24 published a study including 94 ankles, not only confirming the findings by Pagenstert et al. but also showing significant functional improvement and a significant reduction in pain at 3.6 years follow up. Cheng et al.32 described good to excellent results of his 18 patients who underwent distal tibial osteotomies at a mean followup of 48 months. Another study by Takakura et al.33 reported pain relief and improved function in nine patients following realignment of varus deformity. Stamatis et al. performed supramalleolar osteotomies on 23 ankles in 22 patients for painful distal tibial misalignment [22]. A study by Colin et al. 32 showed good to excellent results of supramalleolar osteotomy in 83 patients with good to excellent outcome with low complication rates and failure. Our study shows 87% good to excellent results with over 90% survival of our supramalleolar osteotomy at 6 years is in agreement from the results of the other studies.

We did closing wedge osteotomy for all our supramalleolar osteotomy, although opening wedge osteotomy24,28,30,37 is another option. Closing wedge osteotomy has also shown to give similar outcomes according to Colin et al.32 and Hartstall et al.38 As per Colin et al.32 lateral closing wedge limits tension on soft tissues, reduce wound complications, allow early weight bearing as being stable, limits loss of correction and decreased incidence of nonunion and graft site associated morbidity.

We should never expect complete pain relief following supramalleolar osteotomy .40,41 Even though surgery corrects hind foot alignment the intra-articular deformity, the degeneration might persist which might explain incomplete pain relief. Hintermann et al.39 suggested plafondoplasty for correcting intra articular deformity, but the problem with that is the high probability of damage to the healthy articular cartilage during intra-articular osteotomy. Our study also shows a good pain relief, but not complete relief of pain following supramalleolar osteotomy with VAS score improving to 3.36 ± 1.27 cm from 8.42 ± 0.87 which is in agreement with the literature. But the pain score improved significantly by a mean of 5.06 cm [95% CI - 4.56-5.56], which is still clinically significant for the patient preserving their native mobile joint.

The TAS angle improves significantly with this procedure to normal or near normal. These studies [29, 30, 32,42] showed correction of TAS angle to more than 90°. A correction of more than 90 ° is associated with a good outcome. In our group we achieved a post-operative correction of 90.48 ± 1.36° for our varus deformity correction and 91.34 ±. 66° for valgus deformity. The preoperative talar tilt dictates the postoperative correction. Lee et al.37 suggested the optimum threshold for predicting good correction is up to a talar tilt angle of 7°. In our study the mean talar tilt angle reduced significantly. The preoperative mean was 8 ± 1.95° in varus angle and 5.74 ± 1.43° in valgus angle. This is only moderate deformity and that might have been a contributory factor in our reasonable correction of talar tilt.

According to Barg et al.,43 25% of post osteotomy patient can have progressive symptoms and arthritis and undergo secondary procedures in medium term. In our case only 9.1% of the patient has undergone secondary procedure for progression of their symptom or arthritis at a mean follow-up period of 6 years. This may be because we follow strict inclusion criteria for osteotomy and we confirm with intraoperative arthroscopy that there is no global arthritis, which can cause high failure rates. Complication rates can be high as 22% and nonunion rates up to22% have been reported in literature l.43 Our complication rates has been very low with only one deep wound infection and no non-unions or delayed unions. This may be because closing wedge osteotomies are more stable and hence the good union rate. Again being closing wedge osteotomy we did not use any graft, which can also be a risk factor for wound infection.

Our study has all the weaknesses and limitations of retrospective studies and we have done no opening wedge osteotomy to compare the outcomes between the two procedures. We also do not have a large sample size as it was a retrospective study. As closing wedge osteotomy had lesser risk of non-union we adopted closing wedge osteotomy at the time of study. We have better implants and we have started opening wedge osteotomies now. We also do not know the intra-articular changes in these patients at medium term, as we did not do a second look arthroscopy since it is a retrospective study and we were measuring patients symptomatic improvement and functional outcome than articular cartilage changes. . Our patient age range is also large, which might have caused heterogeneity of the sample. Although the outcome may change in more long-term outcome supramalleolar osteotomy has shown to improve the patient's functional outcome, improve pain and help in correcting the malalignment thereby change the load distribution in the ankle joint.

5

5 Conclusion

In medium term supramalleolar osteotomy is a good joint sparing procedure for patients who have asymmetric ankle osteoarthritis having moderate deformity with more than 50% preserved good cartilage. This procedure has shown to improve the functional outcomes, pain by correcting the malalignment and delay joint sacrificing operations for ankle arthritis.

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