FOOT & ANKLE INTERNATIONAL
Copyright  2011 by the American Orthopaedic Foot & Ankle Society
DOI: 10.3113/FAI.2011.1023
Classification and Treatment of Supramalleolar Deformities
Markus Knupp, MD1 ; Sjoerd A.S. Stufkens, MD2 ; Lilianna Bolliger, MSc1 ; Alexej Barg, MD1 ; Beat Hintermann, MD1
ABSTRACT
Background: Supramalleolar osteotomies are increasingly popu-
lar for addressing asymmetric arthritis of the ankle joint.
Still, recommendations for the indication and the use of addi-
tional procedures remain arbitrary. We preoperatively grouped
different types of asymmetric arthritis into several classes and
assessed the usefulness of an algorithm based on these classifi-
cations for determining the choice of supramalleolar operative
procedure and the risk factors for treatment failure. Methods:
Ninety-two patients (94 ankles) were followed prospectively
and assessed clinically and radiographically 43 months after a
supramalleolar osteotomy for asymmetric arthritis of the ankle
joint. Results: Significant improvement of the clinical scores was
found. Postoperative reduction of radiological signs of arthritis
was observed in mid-stage arthritis. Age and gender did not
affect the outcome. Ten ankles failed to respond to the treat-
ment and were converted to total ankle replacements or fused.
Conclusions: Supramalleolar osteotomies can be effective for
the treatment of early and midstage asymmetric arthritis of
the ankle joint. However, certain subgroups have a tendency
towards a worse outcome and may require additional surgery.
Therefore preoperative distinction of different subgroups is
helpful for determination of additional procedures.
Level of Evidence: II, Prospective Comparative Study
Key Words: Supramalleolar Osteotomy; Asymmetric
Osteoarthritis; Ankle Arthritis; Hindfoot Alignment
1
Department of Orthopaedic Surgery, Kantonsspital Liestal, Liestal, Switzerland.
2
Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, The
Netherlands.
Corresponding Author:
Markus Knupp, MD
Department of Orthopaedic Surgery
Kantonsspital Liestal
CH-4410 Liestal
Switzerland
E-mail: markus.knupp@ksli.ch
For information on pricing and availability of reprints e-mail reprints@datatrace.com
or call 410-494-4994, ext 232.
1023
Liestal, Switzerland; Amsterdam, The Netherlands
INTRODUCTION
Asymmetric joint load with varus or valgus malalign-
ment is a common finding in patients with arthritis of the
ankle joint.1,10,14 This can potentially lead to progressive
joint degeneration and end stage arthritis before permanent
measures, such as ankle fusion or joint replacement, can be
considered a permanent solution.
Supramalleolar osteotomies for the treatment of varus
or valgus type arthritis of the ankle joint (asymmetric
arthritis) have been shown to reduce pain, and improve
function and radiological signs of arthritis, as well as
postpone fusion or replacement surgery.1,10,14,15 Still, data
on the outcome of this procedure are sparse and the
benefits remain unclear as the majority of studies have
assessed only small patient groups with different under-
lying etiologies.1,10,12,14,15 Consequently, recommendations
for the indications for supramalleolar osteotomies and addi-
tional procedures remain somewhat arbitrary.
Therefore, we defined different types of asymmetric
arthritis and used an algorithm based on these classifica-
tions for determining the choice of treatment. The purpose
of the study was to: (1) determine the clinical and radio-
logical outcome after supramalleolar osteotomy; (2) to eval-
uate the usefulness of this novel classification method; and
(3) to determine risk factors for failure of supramalleolar
osteotomies.
MATERIALS AND METHODS
Between 1996 and 2008, a total of 94 ankles in 92 consec-
utive patients (25 female, 67 male) underwent supramalleolar
osteotomy for asymmetric arthritis. All patients presented
with symptomatic ankle varus or valgus malalignment.
Exclusion criteria for supramalleolar osteotomy included
unmanageable joint instability, neurovascular disease, end
stage arthritis, and systemic disease, such as rheumatoid
arthritis.
The patients (mean age 49 years; range 13 to 83 years)
were evaluated prospectively and underwent clinical exam-
ination after a minimum followup of 12 months (mean 43
1024 KNUPP ET AL.
months; range 12 to 126 months) or at time of revision.
Radiographic examination was performed according to a
standard protocol after 2, 3, 6, and 12 months and then annu-
ally. No patients were lost during followup. This study was
approved by our institutional review board, and informed
consent was obtained from all patients.
Operative correction was done according to a novel
algorithm (Figures 1 and 2). Prior to surgery the correction
was planned on the anteroposterior and lateral radiographs.
We assessed the angle of distal tibial joint surface3 (TAS;
α , normal value 91 to 93 degrees) and the tibiotalar angle16
(TTA; β , normal value 91.5 ± 1.2 degrees). The degree of
talar tilt in the ankle mortise was calculated as the difference
between TAS and TTA. According to earlier findings, the
cut-off for clinically relevant ankle tilting was set at four
degrees.2 Two types of ankles were defined: type I consisted
of patients with tilt ≤4 degrees (no tilt, congruent joint) and
type II consisted of patients with tilt >4 degrees (incongruent
joint). Type II patients were further subdivided according to
the degree of narrowing of the joint space with respect to the
subchondral bone. Those patients in whom no bone contact
was evident comprised subgroup A, patients in whom bone
contact was evident, subgroup B, and those in whom the
talus was breaking through the subchondral bone, subgroup
C. Patients with varus feet in whom the joint space narrowing
was mainly found in the medial gutter were classified as type
Fig. 1: Types of asymmetric varus arthritis and treatment algorithm. (SMOT: supramalleolar osteotomy, OT: osteotomy, AD: arthrodesis).
Copyright  2011 by the American Orthopaedic Foot & Ankle Society
Foot & Ankle International/Vol. 32, No. 11/November 2011
III, similar to the classification of Tanaka et al.17 Finally,
lateral view radiographs were used to distinguish between
patients who presented with a centered joint (subgroup c)
and those with an anterior extrusion of the talus out of the
mortise (subgroup e).
Fifty-nine patients underwent arthroscopy at the beginning
of surgery to assess cartilage degeneration. The indications
for arthroscopy included anterior ankle impingement, stage
3 Takakura score7,15 and ankle joint instability. Grade
four lesions, according to the Outerbridge classification,9
underwent microfracturing (14 cases).
For all patients, reconstruction was initiated with the
supramalleolar osteotomy. Varus feet were corrected with
a medial opening wedge osteotomy or a lateral closing
wedge osteotomy. The decision between the lateral or medial
approach was based on the amount of correction needed. In
an extensive medial opening wedge osteotomy, the fibula
may restrict the amount of correction possible, therefore
deformities greater than ten degrees were corrected through
a lateral approach (including an osteotomy of the fibula).6
Processed human cancellous allograft (Tutoplast, Tutogen
Medical GmbH, Neunkirchen am Brand, Germany) was used
to fill the gap in opening wedge osteotomies. Valgus feet were
corrected with a medial closing wedge or a lateral opening
wedge osteotomy (one case). If the talus was extruded
anteriorly (subgroup E), the correction was conducted in a
Foot & Ankle International/Vol. 32, No. 11/November 2011 SUPRAMALLEOLAR DEFORMITIES 1025

Fig. 2: Types of asymmetric valgus arthritis and treatment algorithm. (SMOT: supramalleolar osteotomy, OT: osteotomy, AD: arthrodesis).

Fig. 3: Weightbearing radiographs of a 58-year-old male patient with a varus type II Cc asymmetric arthritis. The images show an anteroposterior, Saltzman
and lateral view, preoperatively and 2 years postoperatively after a supramalleolar opening wedge osteotomy and a calcaneal osteotomy.

Copyright  2011 by the American Orthopaedic Foot & Ankle Society

1026 KNUPP ET AL.
biplanar fashion,1 (e.g., anterior opening or posterior closing
wedge), to improve the talar coverage in the anteroposterior
direction. In all osteotomies, the aim was an overcorrection
of the angle of the distal tibial joint surface of three to five
degrees. Rigid plate fixation with locking screws was used
to secure the correction (Tibiaxis, Integra/Newdeal, Lyon,
France).
After completion of the tibial osteotomy, the ankle mortise
was checked under image intensification. In case of joint
incongruence due to an inadequate length of the fibula, or
if the talus did not follow the medial malleolus, the fibula
was osteotomized and the position and length of the fibula
adjusted. The correction of the fibula was secured with an
additional plate. Examples of varus correction and valgus
correction are shown in Figures 3 and 4.
After the supramalleolar correction, the alignment of the
heel was reassessed clinically. The aim was to achieve a heel
with one to five degrees valgus. Remaining deformity was
addressed with a z-osteotomy of the calcaneus 5 for varus
malalignment or a medial displacement osteotomy for valgus
malalignment.13
Fig. 4: Weightbearing radiographs of a 47-year-old male patient with a
valgus type II Cc asymmetric arthritis, 5 years post-operative. Reduction
of tilting within the ankle mortise and normalization of the alignment is
evident.
Copyright  2011 by the American Orthopaedic Foot & Ankle Society
Foot & Ankle International/Vol. 32, No. 11/November 2011
Ankle instability was addressed using ligament recon-
struction. Reconstruction consisted of ligament suture and
augmentation with the extensor retinaculum. In cases with
a flattened longitudinal arch, corrective fusions (naviculo-
cuneiform joints) or plantar flexion osteotomies (cuneiform
I or first metatarsal) were performed (valgus feet). All addi-
tional procedures are summarized in Table 1.
The patients were permitted to partially bear weight for
eight weeks following surgery. During this time, the ankle
was protected in a splint at night and a walker boot during
the day. Thereafter, full weight bearing was allowed and
physiotherapy was initiated.
Weightbearing radiographs of the foot and ankle were
performed on all patients. Additional hindfoot alignment
view (Saltzman view) radiographs have been performed since
2006.11 The images were evaluated by a board-certified
orthopaedic surgeon specializing in foot and ankle surgery
but not directly involved in the clinical aspects of the study.
The TAS angle was defined by the mid-longitudinal axis
and the plafond of the tibia. The weightbearing axis of the
tibia was defined by bisecting the tibia 8 and 15 cm above the
medial tibial plafond. The TTA angle was measured between
the mid-longitudinal axis and the superior surface of the talus.
On the Saltzman view11 the values were measured in
millimeters and medial offset was by definition a positive
value (normal value 3.2 mm).
Four stages of arthritis were distinguished: Stage 1, no
narrowing of the joint space but evidence of sclerosis and
formation of osteophytes; Stage 2, narrowing of the joint
space medially or laterally; Stage 3, obliteration of the joint
space medially or laterally and contact between adjacent
subchondral bone; Stage 4, complete obliteration of the joint
space with bone on bone contact. This is a modification of the
Takakura score,7,15 which was developed for classification of
varus deformities of the ankle joint.
Clinical evaluation consisted of a questionnaire and a
clinical examination. The questionnaire contained a visual
analogue scale for pain (1 no pain; 10 maximal pain
imaginable), and the AOFAS ankle score (minimal points
0; maximal points 100).4
All experimental data were summarized using descriptive
statistics, including the mean, standard deviation, 95% confi-
dence interval, and range. Pre- and postoperative data were
compared by Wilcoxon rank-sum test. Assessments of differ-
ences in the outcomes between patient groups (e.g., age,
gender, arthritis stage, deformity type) were performed using
Kruskal-Wallis analysis or Mann-Whitney rank-sum testing
where appropriate. A p < 0.05 was considered significant.
RESULTS
A significant improvement of the clinical parameters was
found in all groups. Following surgery, patients in both
the varus and valgus groups presented with significantly
improved AOFAS hindfoot scores and visual analog scores
Foot & Ankle International/Vol. 32, No. 11/November 2011 SUPRAMALLEOLAR DEFORMITIES 1027

Table 1: Additional Procedures Performed Simultaneously with the Supramalleolar Osteotomy in

Varus (a) and Valgus (b) Deformities (OT: osteotomy, AD: arthrodesis)

a) Varus type
Lateral Medial
Number of Fibula Calcaneus Midfoot ligament ligament
Varus type patients OT OT OT/AD repair repair

1c 6 1 0 0 1 0
1e 0 0 0 0 0 0
2Ac 8 2 3 0 4 0
2Ae 6 1 2 3 4 1
2Bc 1 0 0 0 1 0
2Be 2 1 0 0 2 0
2Cc 2 0 1 2 1 0
2Ce 1 0 0 0 1 1
3c 7 1 0 0 4 1
Total 33 6 6 5 18 3

b) Valgus type

1c 24 5 5 8 2 4
1e 1 0 0 0 1 0
2Ac 13 2 8 2 1 3
2Ae 5 0 2 1 1 0
2Bc 8 2 3 0 1 1
2Be 6 0 1 1 2 1
2Cc 2 1 2 0 0 0
2Ce 2 0 2 1 0 1
Total 61 10 23 13 8 10

Table 2: Summary of the Clinical Outcomes (SD: standard deviation, CI: confidence interval)

Preoperative Postoperative
mean ± SD 95% CI mean ± SD 95% CI p value
VAS varus 4.3 ± 1.9 3.6 to 5.1 2.7 ± 2.1 1.9 to 3.5 .001
valgus 4.7 ± 2.0 4.1 to 5.3 2.8 ± 2.5 2.1 to 3.5 <.001
total 4.6 ± 1.9 4.1 to 5.0 2.8 ± 2.3 2.3 to 3.3 <.001
AOFAS varus 55.2 ± 17.9 48.2 to 62.1 70.6 ± 17.0 64.0 to 77.1 .002
valgus 55.8 ± 16.9 50.7 to 60.9 74.2 ± 20.0 68.5 to 80.0 <.001
total 55.6 ± 17.2 51.5 to 59.6 72.8 ± 18.9 68.6 to 77.2 <.001

for pain (p < 0.05) (Table 2). Comparison of the different All osteotomies healed within 12 weeks. Secondary loss
groups with the numbers available showed no significant of correction during followup was not found. Perioperative
differences with respect to the outcome. A trend towards a complications were limited to superficial wound healing
better outcome was found for valgus ankles presenting with problems in five patients and deep infection in one patient,
a preoperative tilt within the mortise. Three patients stated which required surgical debridement and antibiotic treat-
they would not undergo the same procedure again. ment. One patient required reconstruction of the tibialis
Copyright  2011 by the American Orthopaedic Foot & Ankle Society
1028 KNUPP ET AL. Foot & Ankle International/Vol. 32, No. 11/November 2011

Table 3: Summary of the Radiological Findings (SD: standard deviation, CI: confidence interval, TAS: distal tibial articular
surface angle, TTA: tibiotalar angle)

Preoperative values Postoperative values

mean ± SD range 95% CI mean ± SD range 95% CI p value

TAS (deg) varus 84.8 ± 7.0 49 to 92 82.3 to 87.3 91.3 ± 6.1 70 to 100 89.1 to 93.5
valgus 93.0 ± 3.5 86 to 100 92.1 to 93.8 85.4 ± 4.4 76 to 95 84.2 to 86.5
TTA (deg) varus 76.1 ± 8.5 41 to 91 73.1 to 79.1 82.5 ± 7.5 66 to 97 79.8 to 85.2
valgus 97.1 ± 3.9 90 to 110 96.2 to 98.1 88.9 ± 4.4 81 to 100 87.7 to 90.0
Saltzman offset (mm) varus 17.2 ± 12.4 2 to 55 11.0 to 23.3 8.7 ± 8.5 −3 to 26 4.0 to 13.4 0.002
valgus −12.5 ± 9.6 −37 to 2 −16.4 to −8.5 6.0 ± 6.3 −9 to 14 3.0 to 8.9 <0.001
Tilt (deg) varus 9.2 ± 6.1 0 to 20 7.0 to 11.5 9.4 ± 5.7 0 to 22 7.3 to 11.4 0.579
valgus 4.3 ± 3.8 0 to 17 3.4 to 5.3 3.7 ± 3.4 0 to 16 2.8 to 4.6 0.230

Table 4: Arthritis Scores Preoperatively (Horizontal) and Postoperatively (Vertical) for the Varus (a) and the Valgus
Group (b)

a) Varus

Postoperative Takakura stage

1 2 3 4 Total

Preoperative 1 3 0 0 0 3
Takakura stage 2 0 12 2 0 14
3 0 4 11 1 16
Total 3 16 13 1 33

b) Valgus

Postoperative Takakura stage

1 2 3 4 Total

Preoperative 1 14 1 0 1 16
Takakura stage 2 0 23 0 1 24
3 1 7 12 1 21
Total 15 31 12 3 61

anterior tendon due to laceration during surgery. Two
patients developed a painful neuroma of the saphenous
nerve.
Radiologically the alignment improved significantly with
a significant improvement of the arthritis score in stage III
ankles. Anteroposterior and lateral view radiographs were
assessed for all patients. Saltzman view radiographs were
available for 49 cases. In addition to achieving correction of
the ankle joint, a significant improvement of the Saltzman
offset was found (p < 0.05) for both varus and the valgus
malaligned feet. Tilting within the ankle mortise was found
in 60 cases. Postoperative reduction in the tilt was found in
25 cases (Table 3).
Copyright  2011 by the American Orthopaedic Foot & Ankle Society
No significant improvement in the overall Takakura score
was found. However, improvement was found in patients
with stage 3 arthritis (p = 0.005), with the valgus group
showing a better outcome than the varus group (Table 4).
Stratification of patients by age revealed no differences in
clinical or radiological outcome. Similarly, there were also no
differences in outcome between patients of different gender.
Ten ankles failed and were converted to total ankle replace-
ments or fused. Tendencies towards worse outcomes/failures
were found in type I valgus ankles where the fibular length
was not adjusted and in type III varus ankles and patients
with ankle joint instability. The ankles progressed to end
stage arthritis and were converted to total ankle replacements
Foot & Ankle International/Vol. 32, No. 11/November 2011 SUPRAMALLEOLAR DEFORMITIES 1029

Table 5: Overview of Patients Who Underwent Secondary Total Ankle Replacement or Fusion after a Supramalleolar
Osteotomy (TN: talonavicular, SMOT: supramalleolar osteotomy, TAR: total ankle replacement, AD: arthrodesis)

Additional Takakura stage Time to TAR/AD

No. Age Gender Deformity Type procedures before SMOT (months)

3 57 m valgus Ic subtalar and TN fusion 2 24

84 71 m valgus Ic subtalar and TN fusion 2 8
36 53 m valgus Ie microfracturing, lateral 1 19
ligament repair
63 63 m valgus IIAc microfractering, 2 23
calcaneus osteotomy
74 53 m valgus IIAc calcaneus osteotomy 2 24
89 57 m varus IIAe calcaneus osteotomy, 2 9
midfoot osteotomy,
ligament repair
83 66 m varus IIBc lateral ligament repair 3 9
92 55 m varus IIBe lateral ligament repair 3 20
16 56 f varus IIIc lateral ligament repair 3 8
18 51 m varus IIIc subtalar arthrodesis 3 20

(nine cases) or fusion (one case) (Table 5). All failures were
reoperated on within two years of the osteotomy and all of
the respective patients indicated they would still have the
correction of alignment prior to fusion or arthroplasty.
DISCUSSION
In this prospective study, patients with asymmetric arthritis
of the ankle joint were classified into different groups
and treated with a supramalleolar osteotomy. Additional
procedures were added according to an algorithm. After
a mean followup time of 43 months after supramalleolar
osteotomy, a majority of the 94 ankles treated were preserved
and showed significant improvement in the clinical and
radiological outcome parameters.
The majority of previous studies suggest additional proce-
dures when performing a supramalleolar osteotomy for
coronal plane ankle joint deformities. An osteotomy of
the fibula was recommended as a standard procedure in
varus feet15 or for length adjustment in selected valgus
deformities.10 Calcaneal osteotomies were suggested for
supramalleolar deformities in combination with flatfoot
deformity12 or in order to address remaining deviation
after correction of the supramalleolar area.10 Additional
osteotomies or fusions of the midfoot have been suggested
as treatment for flatfoot deformity10,12 or cavovarus feet.10
In our series we used an algorithm to plan the type
of supramalleolar osteotomy preoperatively. Intraoperatively
the necessity for additional procedures, such as calcaneal or
midfoot osteotomies, was then determined according to the
clinical and radiological presentation after the correction of
the supramalleolar deformity.
Copyright  2011 by the American Orthopaedic Foot & Ankle Society
An osteotomy of the fibula was needed to restore joint
congruency or to allow the talus to follow the medial malle-
olus when performing a medial closing wedge osteotomy
of the tibia. This was mainly the case in congruent valgus
joints (type I) and in incongruent valgus joints which were
centered on the lateral view (type II c). In contrast with
earlier reports,15 osteotomy of the fibula for correction
of varus hindfeet was not performed routinely. Calcaneal
osteotomies were performed to address remaining deformity
after correction of the angle of the distal tibial joint surface.
This was mainly necessary in incongruent joints (type II).
Finally, midfoot osteotomies or fusions were performed in
cases of flatfeet10,12 or plantarflexed first rays,10 consis-
tent with previous recommendations. We therefore concur
with earlier recommendations that osseous balancing of
the ankle joint may require not only correction of the
articular surface angle but also may include additional
procedures.
Radiological reduction of tilting within the ankle mortise
in type II ankles was only found in 25 out of 60 cases. This
poor reduction rate was in contrast to the clinical outcome.
Particularly the patients with a preoperative valgus tilt within
the ankle mortise showed a trend towards a greater improve-
ment of the clinical outcome than the congruent joints.
We believe that the discrepancy between the radiological
result and the subjective improvement may result from the
corrected pull of the triceps surae. While the radiographs
are taken in a standing position, the corrected force vector
of the Achilles tendon would reduce the intraarticular peak
loads during gait. This finding may underlie the importance
of an additional calcaneus osteotomy if the hindfoot remains
malaligned after supramalleolar correction in order to address
the eccentric pull of the Achilles tendon.
1030 KNUPP ET AL.
Earlier reports have demonstrated good to excellent
survival rates and improvement in clinical outcomes follow-
ing supramalleolar osteotomy. Takakura et al.14,15,17 de-
scribed relief of pain and reduction of limitations in daily
activities. Cheng et al.1 reported on a selected series of
18 patients. They obtained good or excellent results in all
patients. Pagenstert et al.10 reported on a series of 35 patients
who underwent supramalleolar osteotomies and found that
total ankle replacement or ankle fusion was postponed in
91% of cases by realignment surgery. We were able to
confirm these findings in 94 ankles and found significant
improvement in the AOFAS hindfoot score and significant
reduction in pain in all subgroups (p < 0.05). Complications
were limited to painful neuroma formation in two cases and a
tendon laceration in one case. Furthermore, a large majority
of patients stated that they would undergo the same procedure
again under the same conditions.
Reduction in signs of arthritis on plain radiographs
following supramalleolar osteotomy has been described in
several earlier studies.1,10,14,15 We found a significant reduc-
tion (p < 0.05) in radiological signs of arthritis in ankles
presenting with talar tilt (type II), whereas only tendencies
were evident for the congruent joints (type I). These changes
were independent of age and gender. Another radiological
aspect assessed was whether anterior extrusion of the talus
out of the ankle mortise would adversely affect the outcome.
According to our algorithm, these patients were corrected
with a biplanar osteotomy.1 We found no difference between
the outcomes of ankles centered in the lateral view and
the extruded ankles. However, we believe that the observed
restoration of the joint space may partially be due to the
different radiological presentation of the joint, particularly in
cases treated with biplanar osteotomy.
Ankle varus with the talus additionally tilted within the
mortise and degenerative changes located in the medial
gutter (type III) has been described earlier.8,17 Inferior results
have been observed in patients presenting with this type of
ankle varus17 and a plafond plasty (e.g., an intraarticular
osteotomy) has been recommended to restore the joint
geometry.8 Our series included seven such patients and we
found there was a tendency for them to have a worse outcome
compared with the other groups. We therefore conclude
that the indication for a supramalleolar osteotomy in these
patients should be made very restrictively and only in patients
with an altered TAS.
The present study confirmed the low complication rate of
osteotomies of the distal tibia reported in earlier
studies.10,12,14,15 Ten patients needed secondary joint replace-
ment or ankle fusion. Failed type I ankles were observed only
in the valgus group and retrospective radiological analysis
indicated that the talus remained lateralized, in tight contact
with the fibula, after correction of the distal tibia. We believe
these failures were due to the intraoperative misjudgement of
the surgeon and that the results could have been improved
by an additional fibular osteotomy in order to balance the
Copyright  2011 by the American Orthopaedic Foot & Ankle Society
Foot & Ankle International/Vol. 32, No. 11/November 2011
joint. Failures in type II valgus feet were observed in two
patients. The first one presented with a chronic syndesmotic
insufficiency. The second patient was a heavy smoker who
presented with a deep infection leading to deterioration of
the joint. Failures in incongruent varus ankles (type II) were
found in three cases. In these patients the reason for failure
remained unclear. The only common risk factor in these
patients was severe pre- and postoperative ankle instability.
In accordance with earlier observations,17 the highest failure
rate was in patients presenting with type III varus deformities.
We therefore believe that the main risk factors for failure in
supramalleolar osteotomy are osseous imbalance (e.g., non-
corrected fibula), ligamentous insufficiency and ankles with
intraarticular varus arthritis (type III).
Limitations of the present study include the limited dura-
tion of followup, the small number of patients in some of
the subgroups, the lack of information on the intraarticular
changes, and the use of a non-validated outcome score. The
division of the 94 patients into different groups limited the
number of cases treated with exactly the same procedure.
Furthermore, assessment of the stage of arthritis was based
exclusively on plain radiography. Apart from preoperative
arthroscopy in 59 patients, no information concerning the
intraarticular effect of unloading the degenerated area of the
joint was gathered. Finally, the outcome scores used were not
validated for the procedure described in the present study. A
validated score was established and added to the AOFAS
hindfoot score in our clinic in 2006. Therefore, all patients
treated prior to that date were assessed with a visual analogue
scale for pain and the AOFAS hindfoot score only.
CONCLUSION
In conclusion, the mid-term results following supra-
malleolar osteotomies in patients with midstage arthritis of
the ankle are encouraging. Postoperatively, significant pain
relief and improvement of the AOFAS hindfoot score were
observed. However, to achieve a well balanced ankle joint,
an isolated supramalleolar osteotomy may not be sufficient
in all cases. The suggested classification system helps to
distinguish different types of ankle joint arthritis and eased
preoperative decision making for us. Its prognostic value will
still have to be assessed in larger series.
ACKNOWLEDGMENTS
The authors wish to thank Michael D. Harris for helpful
discussion and for correcting the manuscript.
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