709566

research-article2017
FAIXXX10.1177/1071100717709566Foot & Ankle InternationalDeforth et al

Article
Foot & Ankle International

Supramalleolar Osteotomy for

15
The Author(s) 2017
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DOI: 10.1177/1071100717709566
https://doi.org/10.1177/1071100717709566

Total Ankle Replacement journals.sagepub.com/home/fai

Manja Deforth, MSc1, Nicola Krhenbhl, MD1, Lukas Zwicky, MSc1,

Markus Knupp, MD1, and Beat Hintermann, MD1

Abstract
Background: Persistent pain despite a total ankle replacement is not uncommon. A main source of pain may be an
insufficiently balanced ankle. An alternative to the revision of the existing arthroplasty is the use of a corrective osteotomy
of the distal tibia, above the stable implant. This strictly extraarticular procedure preserves the integrity of the replaced joint.
The aim of this study was to review a series of patients in whom a corrective supramalleolar osteotomy was performed to
realign a varus misaligned tibial component in total ankle replacement. We hypothesized that the supramalleolar osteotomy
would correct the malpositioned tibial component, resulting in pain relief and improvement of function.
Methods: Twenty-two patients (9 male, 13 female; mean age, 62.6 years; range, 44.7-80) were treated with a supramalleolar
osteotomy to correct a painful ankle with a varus malpositioned tibial component. Prospectively recorded radiologic and
clinical outcome data as well as complications and reoperations were analyzed.
Results: The tibial anterior surface angle significantly changed from 85.2 2.5 degrees preoperatively to 91.4 2.9
degrees postoperatively (P < .0001), the American Orthopaedic Foot & Ankle Society hindfoot score significantly increased
from 46 14 to 66 16 points (P < .0001) and the patients pain score measured with the visual analog scale significantly
decreased from 5.8 1.9 to 3.3 2.4 (P < .001). No statistical difference was found in the tibial lateral surface angle and the
range of motion of the ankle when comparing the preoperative to the postoperative measurements. The osteotomy healed
in all but 3 patients on first attempt. Fifteen patients (68%) were (very) satisfied, 4 moderately satisfied, and 3 patients were
not satisfied with the result.
Conclusion: The supramalleolar osteotomy was found to be a reliable treatment option for correcting the varus misaligned
tibial component in a painful replaced ankle. However, nonunion (14%) should be mentioned as a possible complication of
this surgery. Nonetheless, as a strictly extraarticular procedure, it did not compromise function of the previously replaced
ankle, and it was shown to relieve pain without having to have revised a well-fixed ankle arthroplasty.
Level of evidence: Level IV, case series.

Keywords: supramalleolar osteotomy, total ankle replacement (TAR), varus tibial component, tibial anterior surface angle
(TAS), pain

Introduction sagittal plane, the talus may be pushed forward or backward

Persistent pain despite a total ankle replacement (TAR) is
not uncommon. A recent review of the literature revealed
persistent pain in 23% to 60% of ankles after TAR.7 A main
source of pain may be an insufficiently balanced ankle.4,5,17
This may, in particular, be true for the use of a 3-component
prothesis design, where the 2 interfaces allow the polyethyl-
ene insert to move freely. Intrinsic forces may be created
especially if the tibial component is not accurately posi-
tioned.4 If the tibial component is malpositioned in the cor-
onal plane, the talus may be pushed against the malleoli,
resulting in painful impingement and overload of the
malleoli.1 If the tibial component is malpositioned in the
when loading the ankle. Thus the ligamentous structures
and the tendons may be overused, which in return may lead
to pain and impairment during gait.
A malpositioned tibial component can be revised by
exchanging the component in association with a corrective
resection cut to the distal tibia.9 However, removal of a
1
Clinic for Orthopedic and Trauma Surgery, Kantonsspital Baselland,
Liestal, Switzerland
Corresponding Author:
Beat Hintermann, MD, Kantonsspital Baselland, Rheinstrasse 26, Liestal,
4410, Switzerland.
Email: beat.hintermann@ksbl.ch
2 Foot & Ankle International 0(0)
well-anchored, stable component may damage the bone
stock, which makes reinsertion of a component difficult or
impossible. Furthermore, an additional corrective resection
cut of the distal tibia results in further bone loss.
Osteointegration of the new implant into potentially dam-
aged bone stock may be compromised. In addition, such
revision arthroplasty may damage the soft tissue and result
in reactive scarring with loss of function. The overall com-
plication rate after revision of failed TAR was reported to be
as high as 31%.21
An alternative to the exchange of the tibial component is
the use of a corrective osteotomy of the distal tibia, above
the stable implant. This strictly extraarticular procedure
would preserve the integrity of the replaced joint.
The aim of this study was to review a series of patients in
whom a corrective supramalleolar osteotomy was performed
to realign a misaligned tibial component in total ankle
replacement. We hypothesized that the supramalleolar oste-
otomy would correct the malpositioned tibial component,
resulting in pain relief and improvement of function.
Methods
This retrospective analysis of prospectively collected data
was conducted according to the Declaration of Helsinki and
the Guidelines for Good Clinical Practice. The study proto-
col was approved by the local ethics committee (EKNZ
BASEC, approval number 2016-01329).
From May 2004 till October 2013, 22 patients (9 male, 13
female; mean age, 62.6 years; range, 44.7-80) were treated
with a supramalleolar osteotomy to correct a painful unbal-
anced ankle, following a varus implanted tibial component.
The indication for supramalleolar correction was a varus tib-
ial anterior surface (TAS) angle in combination with a stable
tibial component and a painful ankle. The mean interval
between TAR and supramalleolar osteotomy was 32 months
(range, 7-90). For these 22 patients, preoperative and postop-
erative radiologic and clinical data were available at defined
time points. To ensure that the clinical outcome parameters
were related to the supramalleolar osteotomy instead of later
surgery or disease, the postoperative follow-up 24 months
was chosen for analysis. However, complications and reop-
erations that were attributable to the supramalleolar osteot-
omy were analyzed, even if they occurred after the analyzed
follow-up examination. The follow-up for complications and
reoperations was on average 40 months. Hardware removal
was considered as being part of the procedure and was there-
fore not recorded as a complication.
Operative Technique
The supramalleolar osteotomy was performed by or under
direct supervision of 2 foot and ankle surgeons. The distal
tibia was exposed by an incision through the anterior
approach that was also used for the TAR. The height of the
osteotomy was determined under fluoroscopic control.
Then, a 2-mm K-wire was used as a marker for the osteot-
omy. An opening (in 17 patients) or closing wedge osteot-
omy (in 5 patients) was done according to the preoperative
plan. A rule of thumb was that an opening wedge osteotomy
was chosen if the planned correction was rather small and a
closing wedge osteotomy was chosen if the planned correc-
tion was rather big. A distraction or compression device was
used to move the distal tibial graft into the desired position.
An allograft (Tutoplast, Tutogen Medical, Neunkirchen,
Germany) was used in case of an opening wedge osteotomy
to fill the gap. One or 2 interlocking plates were used for
internal fixation.
If the ankle was not fully balanced, a fibular osteotomy
was done (in 7 patients). In the case of a remaining inframal-
leolar deformity, a calcaneal osteotomy was considered to
realign the heel (in 7 patients). These hindfoot procedures
would not have been performed if the ankle arthroplasty had
been well aligned, as verified by visual inspection. No statis-
tical differences were found between the 7 patients with
hindfoot osteotomies and the patients without hindfoot oste-
otomies in terms of pain (visual analog scale [VAS]) and
American Orthopaedic Foot & Ankle Society (AOFAS)
ankle/hindfoot score. Intraoperative ligamentous stress test-
ing was performed under fluoroscopic guidance. If debride-
ment of the joint was necessary, the polyethylene inlay was
exchanged simultaneously (6 patients). However, no signs
of wear were identifiable on the exchanged polyethylene
inlays. The wound was closed in layers and covered by a
compressive dressing. A well-padded short leg splint secured
the foot in neutral position. When the wound conditions
were appropriate, the foot was placed in a stabilizing boot
(VACOped; OPED AG, Steinhausen, Switzerland) for 8 to
10 weeks and partial weight-bearing was permitted. Manual
lymphatic drainage and continuous passive movement of the
ankle was initiated. After osseous healing at the osteotomy
site was confirmed clinically and radiographicallyusually
at 8 to 12 weeks postoperatively, full weight-bearing was
permitted and the rehabilitation program was initiated,
including gradual return to the full level of activities.
Radiographic Assessment
Radiographic assessment included an anteroposterior (AP)
radiograph and a lateral view of the ankle. The alignment of
the tibial component was assessed by measuring the tibial
anterior surface (TAS) angle and the tibial lateral surface
(TLS) angle. Two circles (A and B) were drawn: circle A
was drawn proximal, located between the medial and lateral
cortex, circle B was drawn over the distal tibia. The longitu-
dinal axis of the tibia was placed through the center of cir-
cles A and B. On the AP radiographs of the ankle, the angle
between the tibial component orientation line and the longi-
tudinal axis of the tibia formed the TAS angle (Figure 1).19
On the lateral radiographs, the TLS angle was defined by
Deforth et al 3
Figure 1. Preoperative and follow-up radiographic assessment
of the tibial anterior surface (TAS) angle and the tibial lateral
surface (TLS) angle..
Figure 2. A follow-up anteroposterior (AP) radiograph and a
lateral view of the ankle.
the angle between the longitudinal axis of the tibia and the
tibial component orientation line. All angles were measured
with a digital image processing software (IMS, Imagic,
Glattbrugg, Switzerland) by a research associate who was
not involved in either the surgeries or the pre- and postop-
erative investigations.
Clinical and Functional Outcomes
The clinical examination involved the assessment of the
hindfoot alignment in stance. The ankle range of motion
(ROM) was measured, with the patient in stance and weight-
bearing, using a goniometer applied along the lateral border
of the leg and foot.15 The patients rated pain on a VAS for
pain, 0 points representing no pain and 10 points maximal
pain. The American Orthopaedic Foot & Ankle Society
(AOFAS) ankle/hindfoot score was recorded. The patients
were also asked to indicate their satisfaction with the proce-
dure. The clinical and functional outcomes were collected
preoperatively and postoperatively (Figure 2) by research
associates.
Statistical Data Analysis
Statistical significance level was set as P less than .05. The
normal distribution of the data was tested with a Shapiro-
Wilk test. Paired t tests were carried out by assumption of
normality; otherwise, Wilcoxon signed rank tests were per-
formed. The results were reported as mean standard devi-
ation. In addition to the results of the paired t tests, the effect
size (r) was calculated. As is known, r equal to .1stands
for a small effect, r equal to .3 a medium effect, and an r
equal to.5 is a large effect. IBM SPSS Statistics, version
22 (Armonk, NY) was used for the statistical data analysis.
Results
On average, the TAS angle increased from 85.2 2.5 degrees
preoperatively to 91.4 2.9 degrees postoperatively (P <
.0001, r = 0.91; Figure 3A). No difference was found on
average in the TLS angle (87.3 3.7 degrees preoperatively
vs 88.1 4.2 degrees postoperatively, P = .39, r = 0.19,
Figure 3D).
The VAS pain score decreased from preoperatively 5.8
1.9 to 3.3 2.4 at follow-up (P < .001, r = 0.69; Figure 3B).
Although the main pain was preoperatively in the medial gut-
ter, this pain disappeared postoperatively in all but 3 patients.
The mean AOFAS ankle/hindfoot score increased from pre-
operatively 46 14 to 66 16 points at follow-up (P < .0001,
r = 0.76; Figure 3C). The ROM did not change (preopera-
tively 25.6 9.8; follow-up 23.3 8.7, P = .085, r = 0.37;
Figure 3E). The osteotomy plate was removed in 9 patients
(41%) due to nonunion (in 3 patients) or painful hardware (in
6 patients).
Postoperative, 9 patients (41%) were very satisfied, 6
(27%) satisfied, and 4 (18%) moderately satisfied; 3 (14%)
patients were not satisfied. Two of the patients who were
not satisfied had 1 or more subsequent surgeries because of
postoperative complications.
The osteotomy healed in all (86%) but 3 patients. Of
these, 2 patients had an open wedge osteotomy, and 1
patient had a closing wedge osteotomy. After re-osteosyn-
thesis, the osteotomy healed in all patients. The consolida-
tion of the osteotomy was radiologically confirmed.
Although 1 patient had disturbance of wound healing after
supramalleolar osteotomy, another 3 patients developed
4 Foot & Ankle International 0(0)

Figure 3. Statistical results of the tibial anterior surface (TAS) angle, patients pain (measured with the visual analogue scale [VAS]),
American Orthopedic Foot & Ankle Society (AOFAS) ankle/hindfoot score, tibial lateral surface (TLS) angle, and the range of motion
(ROM).

wound healing problems after re-osteosynthesis or hard-
ware removal. In 1 of these 3 patients, a chronic infection of
the ankle joint occurred thereafter, which could not be man-
aged and finally resulted in a below-knee amputation 5
years after the corrective osteotomy. In 5 patients, a postop-
erative single-photon emission computed tomographic
(SPECT)/CT scan was performed. No loosening of the tib-
ial component was observed in any case. Findings of the
SPECT/CT scan were as follows: osteoarthritis in adjacent
joints (3 patients), painful hardware (1 patient), and a stress
reaction in both malleoli (1 patient). Five patients (23%)
needed at least 1 additional secondary procedure as a result
of impingement or motion restriction in the ankle joint.
Discussion
The aim of this study was to evaluate whether a stable,
well-anchored malpositioned tibial component of a total
ankle replacement system can be successfully corrected
by a supramalleolar osteotomy. The analysis was based
on prospectively collected data in an experienced center
for total ankle replacement and hindfoot reconstruction.
Our results showed very satisfactory radiographical and
clinical results. The selected procedure was successful
with regard to pain relief and function. Pain decreased by
2.5 points on the VAS, which is clinically significant.6,12,20
Functional outcome, as given by the AOFAS ankle/hind-
foot score, improved by 20 points. The ROM did not
change postoperatively.
Although perceived pain on the VAS did not decrease to
zero and 14% of patients were not satisfied by this correct-
ing surgery, the operative outcome was considered favor-
able. This especially when taking into account that most
patients had a previous history of trauma and surgeries, with
substantial damage to the soft tissue around the ankle.
Because of this finding, one cannot expect complete pain
relief. Supporting this view, a systematic review from
Gougoulias etal found that 23% to 60% of patients had
residual pain in the hindfoot after total ankle replacement.7
Despite these favorable results, the complication rate
may raise some concerns; in particular, 3 osteotomies (14%)
did not heal initially. The percentage of nonunions were
higher in our study compared to the literature for supramal-
leolar osteotomies (without TAR).8,14,16,18 In general, previ-
ous surgeries may be a risk factor for complications in any
further surgery.13 Two of the 3 patients with nonunions had
Deforth et al 5
already been operated on previously. Furthermore, 1 patient
was a smoker, which may have contributed to nonhealing of
the osteotomy.10
The overall complication rate after revision of failed TAR
was reported to be as high as 31%.21 The risk of a below-the-
knee amputation after TAR revision has been reported to be
5% and the risk after an ankle fusion 12%.3 Ankle fusion after
failed TAR is a demanding procedure and nonunion rates are
reported to be between 10% to 39%.2,11 Taking this into
account, the complication rate in our patients was fairly low
and we thus continue to consider corrective supramalleolar
osteotomies of the distal tibia as being a valuable treatment
for symptomatic varus misaligned ankles after TAR.
Our study had limitations. First, no control group was
available and therefore the results must be interpreted with
care. Second, only a small number of patients were included
in this study. Nevertheless, we believe that with the num-
bers available, there is enough strength to show that correc-
tive supramalleolar osteotomies are a valuable measure to
balance the misaligned replaced ankle.
In conclusion, supramalleolar osteotomies were found to
be an effective and reliable method to correct the varus mal-
positioned tibial component in a painful ankle replacement.
As a strictly extraarticular procedure, it did not compromise
function of the previously replaced ankle, and it was shown
to relieve pain without having to debride the joint. However,
nonunion (14%) should be mentioned as a possible compli-
cation of this surgery. We nevertheless consider this treat-
ment option as our first choice for correcting a malpositioned
tibial component after TAR.
Acknowledgment
The authors thank Tamara Horn for the proof reading.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest
with respect to the research, authorship, and/or publication of this
article: Beat Hintermann, MD, has a patent pending.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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