Joint-preserving options for eccentric ankle osteoarthritis

Supramalleolar osteotomy is an increasingly popular joint-preserving option for treatment of mild-to-moderate arthritis with deformity. Mohammad El Sayad, Prasad Karpe, P. Raju and Rajiv Limaye review the literature available and describe why they consider the technique to be suitable for treatment of patients with asymmetric valgus or varus ankle arthritis.

 

Osteoarthritis (OA) of the ankle is often preceded by trauma to the ankle joint [1,2], but there are other secondary causes, including infection, talar osteonecrosis and Charcot neuropathy [3]. It is a condition that can result in significant pain and functional disturbances and it affects approximately 1 per cent of the adult population [4,5]. Patients start showing symptoms approximately 15 years earlier than those with hip or knee arthritis [6].

Treatment options can be joint sacrificing or joint preserving. Joint-sacrificing options include ankle arthrodesis [7–9] and total ankle arthroplasty [10–13]

Ankle joint arthrodesis has been shown to be associated with functional restriction, gait abnormalities and the development of secondary degenerative changes in the adjacent joints [10–18].

Although good initial results have been reported for total ankle arthroplasty [12,16,17,19], the long-term outcomes of this procedure are yet to be investigated [13,20,21].

Supramalleolar osteotomy is a joint-preserving option for patients with ankle OA, especially those with ankle malalignment. Other joint-preserving options include arthroscopic debridement [25,26], shell allograft procedures [27,28] and distraction arthroplasty [29,30], but these options do not tackle the underlying deformity and eccentric loading, particularly in patients with altered mechanics [22–24] (see Figure 1).

 

Review of literature

Supramalleolar osteotomy is an established joint-preserving treatment option in patients with eccentric cartilage loss. It also addresses deformity and eccentric loading in mechanically disturbed joints [22–24].

Previous studies have shown good-to-excellent outcomes after supramalleolar osteotomy. For example, a series published by Pagenstert et al. [31] reported a good outcome in 35 patients who underwent the treatment – with 91 per cent of patients having successfully avoided total ankle arthroplasty or ankle arthrodesis after five years – while Knupp et al. [24] published a study including 94 ankles that not only confirmed Pagenstert’s findings, but also showed significant functional improvement and 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 follow up of 48 months, and another study by Takakura et al. [34] reported pain relief and improved function in nine patients following realignment of varus deformity. Stamatis et al. [22] performed supramalleolar osteotomies on 23 ankles in 22 patients for painful distal tibial malalignment: two patients had non-union of the osteotomy; the remaining osteotomies healed at a mean time of 14 weeks; significant improvement of the AOFAS score was noted.

 

Our experience

In our practice, we have treated 33 patients with eccentric OA of the ankle using a closing wedge supramalleolar osteotomy, performed by one surgeon between 2008 and 2015 (Figures 2a and 2b). Twenty-one of the patients were deformed in varus and 12 were in valgus. The average age of the patients was 57 years old.

In our series, the inclusion criteria were all symptomatic ankle OA with varus or valgus ankle deformity on X-ray and single compartment OA (Figures 3a and 3b). These patients had a failure of conservative treatment. We only included ankles that showed single coronal plane deformity (varus or valgus).

All of the patients included in our study had a good range of motion, and all had a deformity contraindicating ankle replacement and were not keen for fusion. We have excluded from our study all ankles exhibiting associated sub-talar arthritis, ankles with concentric arthritis of the ankle or inflammatory arthritis, and patients with neuropathic disorder or vascular insufficiency.

We recorded AOFAS score for patients before and after surgery. Patients had lower limb examination to rule out any other proximal deformities. They also had standing X-rays to rule out any abnormalities of the distal tibia and Saltzman view to exclude deformity in the hindfoot.

Our patients underwent a standardised post-operative management plan which involved a below-knee cast with no weight-bearing for six weeks, followed by six weeks in a moonboot and regular physiotherapy. All patients received deep venous thromboembolism prophylaxis following their operations and they all had regular follow up at three, six, 12, 18 and 24 months.

Over an average of 25 months of follow up, our results showed that all 33 cases healed with no evidence of infection or non-union; time to radiological union ranged between 8 and 10 weeks post-op. The mean AOFAS score prior to the osteotomies was 34.8; this showed significant improvement to 79.9 following the procedure.

The mean ankle range of movement was 50 degrees prior to surgery and 40 degrees after surgery (see Figure 4).

 

We reported four failures: one was revised to ankle replacement at 24 months following osteotomy, with the osteotomy being the contributing factor to the deformity being corrected and allowing arthroplasty surgery; the other three underwent ankle fusion due to worsening symptoms of arthritis between 18 and 20 months following supramalleolar osteotomy (Figure 5).

 

 

Discussion

Studies in the past showed that in isolated supramalleolar deformity, varus deformity of the ankle resulted in medial overload of the tibiotalar joint, whereas valgus deformity resulted in a shift toward the lateral side of the joint. It was also reported that supramalleolar varus and valgus deformities affect force and load transfer in both coronal and sagittal planes [36].

Supramalleolar osteotomy is a joint-preserving surgical treatment for patients with asymmetric valgus or varus ankle arthritis. Studies showed that 50 per cent of all patients with ankle OA have malalignment [34,35]. Supramalleolar osteotomies are becoming an increasingly popular option for treatment of mild-to-moderate arthritis with deformity. The aim behind performing this procedure is to preserve motion and correct malalignment, which then results in redistributing the forces and offloading the damaged areas, therefore improving the overall function of the ankle joint. Takakura et al. [34] and Knupp et al. [24] also reported significant improvement in pain following osteotomies.

Supramalleolar osteotomy is indicated in asymmetric OA of the ankle with valgus or varus deformities. At least 50 per cent of the tibiotalar joint surface should be preserved. It is also indicated in isolated osteochondral lesion of the medial or lateral aspect of the tibiotalar joint [40]. Another indication for supramalleolar osteotomies is to optimise alignment of total ankle arthroplasty or ankle arthrodesis in the treatment of end-stage ankle OA [37–39].

The absolute contraindications for the procedure include end-stage degenerative disease; hind-foot instability that cannot be managed with ligament reconstruction; infections; vascular or neurological deficiency; neuropathic disorders; and non-compliant patients. Relative contraindications include age above 70, poor bone quality of the distal tibia and/or talus and tobacco use.

Our study showed an excellent outcome following supramalleolar osteotomies that also supported previous studies [24,31,32,34,35]. We were able to demonstrate significant improvement in functional outcomes assessed using the AOFAS scoring system, significant reduction in pain scores and low infection rates. Radiologically and clinically, all osteotomies healed with no evidence of non-union. X-rays also demonstrated that tibial–ankle surface angles in both the coronal and the sagittal planes were significantly improved; however, the radiographic degenerative changes in the ankle joint showed no evidence of progression [22].

Other than the usual complications associated with all surgical procedures – such as injuries of neurovascular structures and tendons, wound healing problems and infections – the rate of procedure-specific complication is very rare [41,42].

Mal-union or non-union at the osteotomy site may occur due to inappropriate surgical technique, non-anatomical reduction of the osteotomy or non-compliance of patients with post-operative instructions [37]; however, our study reported no bone healing complications and all our patients showed radiological healing by 8–10 weeks after surgery.

Following the procedure, OA might still progress requiring further surgical treatment in the form of total ankle replacement or ankle arthrodesis. A study by Knupp et al. [24] that included 94 ankles, reported that ten of them failed, nine were converted to total ankle replacement and one was converted to ankle arthrodesis. In our study, three out of 33 patients were converted to ankle arthrodesis and one was converted to an ankle joint replacement. In total, we had four failures out of 33 supramalleolar osteotomies performed.

In conclusion, supramalleolar osteotomy is a viable option for mild/moderate arthritis with deformity as it preserves motion and corrects malalignment, and therefore helps improve function and reduce pain. It is associated with low complication rates and high patient satisfaction [23,39] and, in the event of failure, future replacements or fusions are not compromised.

 

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Mohammad El Sayad is CT2 in orthopaedics and trauma; Prasad Karpe is ST3 in orthopaedics; P Raju is consultant radiologist; and Rajiv Limaye is consultant orthopaedic surgeon at University Hospital of North Tees and Hartlepool.