The Teramoto distal tibial oblique osteotomy (DTOO): surgical technique and applicability for ankle osteoarthritis with varus deformity

Tsukasa Teramoto,Shota Harada,Takasi Matsushita,Yukinobu Nishi,Motoyuki Takaki,Narutaka Kato,Tomohiko Asahara,Nobuyuki Takenaka,Ootuka Kazutaka,Kiyoto Kinugsa,Kouitiro Tasiro,Yosiaki Makino

doi:10.1007/s11751-018-0307-0

Abstract

We have devised a medial peri-articular osteotomy, the distal tibial oblique osteotomy (DTOO), and have used this technique since 1994 for ankle osteoarthritis of advanced and late stages associated with varus inclination. This report describes the surgical technique and its applicability. DTOO can be used for cases of varus ankle osteoarthritis with a range of the ankle joint movement of at least 10° or more. The osteotomy is obliquely directed cut across the distal tibia from proximal-medial to distal lateral and is of an opening-wedge type with the centre of rotation coincident with the centre of the tibiofibular joint. A laminar spreader instrument is inserted in the osteotomy to open the wedge until the lateral surface of the talar body is seen on X-ray to be in contact and congruent with medial articular surface of the lateral malleolus. Common obstacles which may prevent this contact and congruency are bony spurs present on the anterior side of fibula or on the lateral side of the tibia; these require removal. The opening-wedge osteotomy is held in position by an Ilizarov external fixator or internally fixed with a plate. Bone graft is taken from the iliac crest and inserted into the open wedge. If, after completion of the osteotomy, the dorsiflexion angle of the ankle joint does not exceed 0°, a Z-lengthening is performed of the Achilles tendon. In the DTOO for ankle osteoarthritis, the contact area of the ankle joint increases and decreases the load pressure per unit area. Furthermore, as the width of the ankle mortice is restored through the realignment of the body of the talus, instability at the ankle joint decreases. There is additional improvement with restoration of the inclination of the distal tibial articular surface as this directs the hindfoot valgus and corrects the alignment of the foot, with consequent improvement of ankle pain.

Highlights

Supramalleolar low tibial osteotomies (LTO) [12–14], total ankle arthroplasty (TAA) [6, 7] and arthrodesis of the ankle (AA) [1–3] have been performed for theKōchi, Japan surgical treatment for ankle osteoarthritis
It is considered that the TAA maintains a range of the ankle joint movement, it not suited for patients who anticipate manual work or active leisure pursuits as daily undertakings [6, 7]
TAA maintains ankle joint movement and is suited for advanced and late stages; it is not suited for patients where there is severe deformity associated with the distal tibial articular surface, and sports and heavy manual work activities are limited after surgery [6, 7]

Summary

Introduction

Supramalleolar low tibial osteotomies (LTO) [12–14], total ankle arthroplasty (TAA) [6, 7] and arthrodesis of the ankle (AA) [1–3] have been performed for the. Two 2.4-mm Kirschner are added percutaneously from the medial malleolus to augment stability and removed once healing is complete (Fig. 2d) In those patients in whom the dorsiflexion angle of the ankle joint does not exceed plantigrade after completion of the osteotomy and bone grafting, a Z-lengthening is performed on the Achilles tendon. When a hemiarthroplasty or total knee arthroplasty has been used for the ipsilateral knee joint or if the Ilizarov external fixator is declined by the patient, locking plate fixation is used For such cases, the tension created on the medial side makes plate insertion on the same medial surface difficult, and as such, a compromise to the degree of correction has to be made in order to facilitate skin closure over the plate. The Ilizarov external fixator is removed 3 months after surgery (Figs. 4a–d, 5a–c, 6a–d, 7a–c)

Discussion

Conclusion

Compliance with ethical standards