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 . 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 .
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.  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.  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.  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.  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 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.
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).
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 .
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.  and Knupp et al.  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 . 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 .
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 ; 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.  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.
- Saltzman CL, Salamon ML, Blanchard GM, et al. Epidemiology of ankle arthritis: Report of a consecutive series of 639 patients from a tertiary orthopaedic center. Iowa Orthop J 2005; 25(1):44-46
- Valderrabano V, Horisberger M, Russell I, et al. Etiology of ankle osteoarthritis. Clin Orthop Relat Res 2009; 467(7):1800-1806
- Thomas R, Daniels T. Ankle arthritis. J Bone Joint Surg Am 2003; 85:923-936
- Barg A, Pagenstert GI, Hügle T, et al. Ankle osteoarthritis: Etiology, diagnostics, and classification. Foot Ankle Clin 2013; 18(3):411-426
- Glazebrook M, Daniels T, Younger A, et al. Comparison of health-related quality of life between patients with end-stage ankle and hip arthrosis. J Bone Joint Surg Am 2008; 90(3):499-505
- Buckwalter JA, Saltzman C, and Brown T. The impact of osteoarthritis: Implications for research. Clin Orthop Relat Res 2004; 427 (suppl):S6-S15
- Hendrickx RP, Stufkens SA, de Bruijn EE, et al. Medium- to long-term outcome of ankle arthrodesis. Foot Ankle Int 2011; 32(10): 940-947
- Nihal A, Gellman RE, Embil JM, Trepman E. Ankle arthrodesis. Foot Ankle Surg 2008; 14(1):1-10
- Plaass C, Knupp M, Barg A, Hintermann B. Anterior double plating for rigid fixation of isolated tibiotalar arthrodesis. Foot Ankle Int 2009; 30(7):631-639
- Barg A, Elsner A, Anderson AE, Hintermann B. The effect of three-component total ankle replacement malalignment on clinical outcome: Pain relief and functional outcome in 317 consecutive patients. J Bone Joint Surg Am 2011; 93(21):1969-1978
- Barg A, Zwicky L, Knupp M, et al. HINTEGRA total ankle replacement: Survivorship analysis in 684 patients. J Bone Joint Surg Am 2013; 95(13):1175-1183
- Gougoulias N, Khanna A, Maffulli N. How successful are current ankle replacements? A systematic review of the literature. Clin Orthop Relat Res 2010; 468(1):199-208
- Nunley JA, Caputo AM, Easley ME, Cook C. Intermediate to long-term outcomes of the STAR Total Ankle Replacement: The patient perspective. J Bone Joint Surg Am 2012; 94(1):43-48
- Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am 2001;83(2): 219-228
- Fuchs S, Sandmann C, Skwara A, Chylarecki C. Quality of life 20 years after arthrodesis of the ankle. J Bone Joint Surg Br 2003; 85(7):994-998
- Haddad SL, Coetzee JC, Estok R, et al. Intermediate and long-term outcomes of total ankle arthroplasty and ankle arthrodesis: A systematic review of the literature. J Bone Joint Surg Am 2007; 89(9):1899-1905
- Barg A, Wimmer MD, Wiewiorski M, et al. Total ankle replacement. Dtsch Arztebl Int 2015; 112(11):177-184
- Zaidi R, Cro S, Gurusamy K, et al. The outcome of total ankle replacement: A systematic review and meta-analysis. Bone Joint J 2013; 95-B (11):1500-1507
- Wood PL, Sutton C, Mishra V, Suneja R. A randomised, controlled trial of two mobile bearing total ankle replacements. J Bone Joint Surg Br 2009; 91(1):69-74
- Brunner S, Barg A, Knupp M, et al. The Scandinavian total ankle replacement: Long-term, eleven to fifteen-year, survivorship analysis of the prosthesis in seventy-two consecutive patients. J Bone Joint Surg Am 2013; 95 (8):711-718
- Mann JA, Mann RA, Horton E. STAR ankle: Long-term results. Foot Ankle Int 2011; 32(5):S473-S484
- Stamatis ED, Cooper PS, Myerson MS. Supramalleolar osteotomy for the treatment of distal tibial angular deformities and arthritis of the ankle joint. Foot Ankle Int 2003;24(10):754-764
- Hintermann B, Barg A, Knupp M. Corrective supramalleolar osteotomy for malunited pronation-external rotation fractures of the ankle. J Bone Joint Surg Br 2011;93(10):1367-1372
- Knupp M, Stufkens SA, Bolliger L, et al. Classification and treatment of supramalleolar deformities. Foot Ankle Int 2011;32(11):1023-1031
- Scholten PE, Sierevelt IN, van Dijk CN. Hindfoot endoscopy for posterior ankle impingement. J Bone Joint Surg Am 2008; 90(12):2665-2672
- Tol JL, Verheyen CP, van Dijk CN. Arthroscopic treatment of anterior impingement in the ankle. J Bone Joint Surg Br 2001;83(1):9-13
- Jeng CL, Myerson MS: Allograft total ankle replacement: A dead ringer to the natural joint. Foot Ankle Clin 2008;13(3):539-547
- Meehan R, McFarlin S, Bugbee W, Brage M. Fresh ankle osteochondral allograft transplantation for tibiotalar joint arthritis. Foot Ankle Int 2005;26(10):793-802
- Nguyen MP, Pedersen DR, Gao Y, et al. Intermediate term follow-up after ankle distraction for treatment of end-stage osteoarthritis. J Bone Joint Surg Am 2015;97(7):590-596
- Saltzman CL, Hillis SL, Stolley MP, et al. Motion versus fixed distraction of the joint in the treatment of ankle osteoarthritis: A prospective randomized controlled trial. J Bone Joint Surg Am 2012;94(11):961-970
- Pagenstert G, Knupp M, Valderrabano V, Hintermann B. Realignment surgery for valgus ankle osteoarthritis. Oper Orthop Traumatol 2009;21(1):77-87
- Cheng YM, Huang PJ, Hong SH, et al. Low tibial osteotomy for moderate ankle arthritis. Arch Orthop Trauma Surg 2001;121(6):355-358
- Takakura Y, Takaoka T, Tanaka Y, et al. Results of opening wedge osteotomy for the treatment of a post-traumatic varus deformity of the ankle. J Bone Joint Surg Am 1998;80(2):213-218
- Horisberger M, Valderrabano V, Hintermann B. Posttraumatic ankle osteoarthritis after ankle-related fractures. J Orthop Trauma 2009;23(1):60-67
- Puno RM, Vaughan JJ, Stetten ML, Johnson JR. Long-term effects of tibial angular malunion on the knee and ankle joints. J Orthop Trauma 1991;5(3):247-254
- Knupp M, Stufkens SA, van Bergen CJ, et al. Effect of supramalleolar varus and valgus deformities on the tibiotalar joint: A cadaveric study. Foot Ankle Int 2011;32 (6):609-615
- Barg A, Pagenstert GI, Horisberger M, et al. Supramalleolar osteotomies for degenerative joint disease of the ankle joint: Indication, technique and results. Int Orthop 2013;37(9):1683-1695
- Barg A, Saltzman CL: Single-stage supramalleolar osteotomy for coronal plane deformity. Curr Rev Musculoskelet Med 2014;7(4):277-291
- Pagenstert GI, Hintermann B, Barg A, et al. Realignment surgery as alternative treatment of varus and valgus ankle osteoarthritis. Clin Orthop Relat Res 2007;462:156-168
- Valderrabano V, Miska M, Leumann A, Wiewiorski M. Reconstruction of osteochondral lesions of the talus with autologous spongiosa grafts and autologous matrix-induced chondrogenesis. Am J Sports Med 2013;41(3):519-527
- Becker AS, Myerson MS. The indications and technique of supramalleolar osteotomy. Foot Ankle Clin 2009;14(3):549–561
- Benthien RA, Myerson MS. Supramalleolar osteotomy for ankle deformity and arthritis. Foot Ankle Clin 2004;9(3):475-487
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.