Low Tibial Osteotomy Research Articles

Protective Kirschner Wire Fixation to Reduce the Effect of Lateral Hinge Fracture During the Medial Opening Wedge Low Tibial Osteotomy: A Technical Note

Protective Kirschner Wire Fixation to Reduce the Effect of Lateral Hinge Fracture During the Medial Opening Wedge Low Tibial Osteotomy: A Technical Note

Radiographic Outcomes of Proximal vs Distal Syndesmotic Low Tibial Osteotomy

Category: Ankle Arthritis; Ankle Introduction/Purpose: We aimed to determine whether the location of tibial osteotomy affects the outcome during low tibial osteotomy (LTO) with fibular osteotomy for varus ankle arthritis by comparing proximal syndesmotic (PS) and distal syndesmotic (DS) tibial osteotomy. Methods: We retrospectively reviewed the radiographic findings of 50 cases (among 47 patients) who underwent LTO with fibular osteotomy for varus ankle arthritis. The enrolled patients were divided into two groups according to the location of the tibial osteotomy: the PS group (25 cases, 24 patients) and the DS group (25 cases, 23 patients). Radiographic parameters were compared between the two groups. Results: There were no significant differences in tibial anterior and lateral surface angles, tibiomedial malleolar angle, talar center migration, and intermalleolar distance correction between the two groups (all, P>.05). However, the decreases in talar tilt (TT) and talocrural angle (TCA) were more pronounced in the DS group than in the PS group (both P<.05). Among patients with TT >=8 degrees, a greater decrease in TT (+1.0 degrees vs. -2.8 degrees) and TCA was observed in the DS group, while the PS group demonstrated greater increases in TCA and intermalleolar distance (all, P<.01). Conclusion: In this series, DS tibial osteotomy combined with fibular osteotomy was a more effective operative option than PS tibial osteotomy to correct both extra- and intra-articular deformity for varus ankle arthritis.

Low Tibial Valgization Osteotomy for Varus Ankle Arthritis: Does Age Effect the Outcome?

Category:Ankle; Ankle ArthritisIntroduction/Purpose:Evidence-based literature identifying the age limit for low tibial valgization osteotomy (LTO) is lacking to date. We addressed the following research questions: (1) is LTO effective for ankle arthritis in patients over 65 years?; (2) does patients' age alter the effectiveness of LTO?; and (3) does preoperative Takakura stage affect the degree of correction in patients over 65 years?Methods:We retrospectively reviewed the radiographic and clinical findings of 49 cases which underwent LTO. Patients were divided into two groups according to age at operation (19 cases in group 1 aged >=65 years and 30 cases in group 2 aged <65). Patients in a single group were regrouped into two subgroups according to preoperative Takakura stage (stage II+IIIA versus IIIB) to determine if the degree of correction varied in Takakura stage IIIB.Results:Significant changes in radiographic parameters were observed with no significant differences in the amounts of correction between groups 1 and 2. Comparison of Takakura stage II+IIIA in group 1 to that in group 2 and stage IIIB in group 1 to that in group 2 revealed no significant differences in the amounts of correction.Conclusion:LTO could be indicated for patients over 65 years if patient selection was appropriate. LTO in patients over 65 years showed similar radiographic improvements to those in younger patients, and the correction was successfully maintained during the follow-up period. The correctional power of all radiographic parameters did not vary by preoperative Takakura stage.

Low Tibial Valgization Osteotomy for More Severe Varus Ankle Arthritis

Category:Ankle ArthritisIntroduction/Purpose:Low tibial valgization osteotomy with medial opening wedge (LTO) is generally indicated for ankle arthritis with a small talar tilt (TT). We addressed the following research questions: the efficacy of LTO for more significant varus ankle arthritis, the effect of additional inframalleolar correction followed by LTO, and the preoperative or operation related factors influencing postoperative TT decrease.Methods:We retrospectively reviewed the radiographic and clinical findings of 31 patients with more significant varus ankle arthritis (>=8 degrees) who underwent LTO or LTO plus inframalleolar correction. We grouped the included patients according to combination with inframalleolar correction and postoperative decreased TT. Furthermore, a binary logistic regression analysis was performed to determine the factors influencing postoperative TT decrease.Results:Even though the mean TT was unchanged postoperatively (from 12.1 to 9.9 degrees, P =.052), clinical parameters were significantly increased. In the group with concomitant inframalleolar correction, we found that TT was more corrected (3.9 vs 1.8 degrees, P =.023) with a greater lateralization of the talar center and a greater correction of the hindfoot alignment to valgus. The results of the binary logistic regression analysis showed a significant relationship between postoperative decreased TT and preoperative talar center migration (P =.016), hindfoot alignment angle (P =.033), hindfoot moment arm (P =.041), and hindfoot alignment ratio (P =.016).Conclusion:LTO in more significant varus ankle arthritis could result in clinical improvement, although TT was not significantly changed. We recommend adding inframalleolar correction after LTO for the patients with more significant varus ankle arthritis.

One-stage tibial deformity correction and ankle arthrodesis for ankle osteoarthritis and tibial malalignment after low tibial osteotomy

IntroductionThere are no reports on one-stage corrective tibial opening wedge osteotomy and arthrodesis for osteoarthritis of the ankle and tibial malalignment after distal tibial osteotomy.Presentation of caseThe patient was a 70-year-old woman who presented with complaints of ankle pain and lower limb deformity after tibial osteotomy performed for ankle arthritis 17–18 years earlier. Clinical examination revealed marked swelling around the ankle joint and pain and tenderness at the joint line. Imaging showed tibial malalignment and severe osteoarthritic changes in the ankle. The patient had valgus deformity of 21° and recurvatum deformity of 4°. In two months, she admitted to Department of Orthopedics at Tokushima University Hospital in Japan and we performed one-stage corrective tibial opening wedge osteotomy and ankle arthrodesis with an anterolateral plate through a lateral longitudinal incision. After removal of the previous implants, the remaining articular cartilage and osteophytes were removed from the tibial and talar surfaces. After debridement of the talar trochlea and tibial plateau, the center of rotation and angular deformity of the tibia was cut transversely and a 1-cm bone graft obtained from the removed fibula was inserted into the osteotomy site, which decreased the tibial malalignment. An anterolateral locking plate was inserted over the anterior and lateral sides of the tibia, and the ankle was fused using 2 cannulated screws.DiscussionThe patient wore an above-knee splint for 6 weeks to avoid weight-bearing followed by gradual weightbearing with a brace thereafter. Osseous fusion was achieved after about 3.5 months. Radiographs obtained at the 2-year follow-up visit showed complete union of the tibia and talus. Full correction of valgus and recurvatum deformity was achieved, and the patient was able to perform daily activities with almost no pain.ConclusionWe reported a rare case of ankle osteoarthritis and tibial malalignment that was successfully treated with one-stage corrective tibial opening wedge osteotomy and ankle arthrodesis using an anterolateral plate via a transfibular approach.

Radiological assessments and clinical results of intra-articular osteotomy for traumatic osteoarthritis of the ankle

IntroductionTraumatic osteoarthritis of the ankle joint caused after malleolar fractures of the ankle and tibial plafond fractures are frequently observed in comparatively young and highly active patients. Since the ankle movement in these patients is in general, comparatively favorable, orthopedists may sometimes have difficulty in deciding on a treatment policy. In our department, when treating traumatic osteoarthritis patients having a movable range within their ankle joints, we proactively applied distal tibial oblique osteotomy (DTOO) developed by Dr. Teramoto in 1994 or intra-articular osteotomy developed based on DTOO concepts such as distal tibial intra-articular osteotomy (DTIO) and distal fibular oblique osteotomy (DFOO).The objectives of the current study are to radiologically assess the ankle joint after intra-articular osteotomy for traumatic ankle osteoarthritis and evaluate the change in configuration of the ankle joint. This study summarizes the clinical results of intra-articular osteotomy obtained through the above-mentioned study. Patients and methodsThe subjects of this study were 20 patients diagnosed with traumatic osteoarthritis who were surgically treated for a total of 20 ankles. All patients underwent treatment with intra-articular osteotomy and were evaluated retrospectively for the following parameters: surgical procedure, fixation devices, clinical results based on the Japanese Society for Surgery of the Foot ankle/hindfoot scale (hereafter, JSSF scale) and post-operative adverse events. They were also assessed radiologically with pre- and post-operative anterior-posterior (AP) and lateral weight-bearing ankle radiographs. ResultsThe 20 patients consisted of 12 males and 8 females. The median age at surgery was 49 years old (range 14 - 87 years old) and the average follow-up period was 42 months (range 19 to 121 months). DTOO was applied to 10 cases, DFOO to 2 cases, DTOO and DFOO to 2 cases, medial-distal tibial intra-articular osteotomy (M-DTIO) and DFOO to 1 case, lateral-distal tibial intra-articular osteotomy (L-DTIO) and DFOO to 3 cases, M-DTIO followed by DTOO and DFOO to 1 case, and DTOO followed by low tibial osteotomy (LTO) to 1 case. Fixation devices utilized included circular external fixator for 15 cases, locking compression plate (LCP) to 3 cases, LCP and Kirschner-wire (K-wire) to 1 case, and screw and K-wire to 1 case. Radiological assessment revealed significant changes in the following parameters after surgery: tibial ankle surface angle (TAS, P= 0.0203), tibiotalar surface angle (TTS, P= 0.0021), medial malleolar angle (MMA, P= 0.0217), empirical axis (EA, P= 0.0019), fibular angle (FA, P= 0.0002), talar tilt angle (TTA, P= 0.0374), and tibial lateral surface angle (TLS, P= 0.0279). The JSSF scale also improved significantly after surgery (pre-operative JSSF scale: 51.1±11.0, post-operative JSSF scale: 89.2±8.2), p=0.0001. ConclusionIntra-articular osteotomy may change the radiological configuration of the ankle in a weight-bearing state. The present study showed very good short-term clinical results. Intra-articular osteotomy can prove a viable surgical option applicable for treatment of patients with traumatic ankle osteoarthritis having a reasonable range of motion within their ankle joints.

Radiographic Outcomes of Proximal vs Distal Syndesmotic Low Tibial Osteotomy.

We aimed to determine whether the location of tibial osteotomy affects the outcome during low tibial osteotomy (LTO) with fibular osteotomy for varus ankle arthritis by comparing proximal syndesmotic (PS) and distal syndesmotic (DS) tibial osteotomy. We retrospectively reviewed the radiographic findings of 50 cases (among 47 patients) who underwent LTO with fibular osteotomy for varus ankle arthritis. The enrolled patients were divided into 2 groups according to the location of the tibial osteotomy: the PS group (25 cases, 24 patients) and the DS group (25 cases, 23 patients). Radiographic parameters were compared between the 2 groups. There were no significant differences in tibial anterior and lateral surface angles, tibiomedial malleolar angle, talar center migration, and intermalleolar distance correction between the 2 groups (all P > .05). However, the decreases in talar tilt (TT) and talocrural angle (TCA) were more pronounced in the DS group than in the PS group (both P < .05). Among patients with TT ≥8 degrees, a greater decrease in TT (+1.0 degrees vs -2.8 degrees) and TCA was observed in the DS group, whereas the PS group demonstrated greater increases in TCA and intermalleolar distance (all P < .01). In this series, DS tibial osteotomy combined with fibular osteotomy was a more effective operative option than PS tibial osteotomy to correct both extra- and intra-articular deformity for varus ankle arthritis. Level III, retrospective comparative study.

Low tibial valgization osteotomy for varus ankle arthritis – does age effect the outcome?

BackgroundEvidence-based literature identifying the age limit for low tibial valgization osteotomy (LTO) is lacking to date. We addressed the following research questions: (1) is LTO effective for ankle arthritis in patients over 65 years?; (2) does patients’ age alter the effectiveness of LTO?; and (3) does preoperative Takakura stage affect the degree of correction in patients over 65 years? MethodsWe retrospectively reviewed the radiographic and clinical findings of 49 cases which underwent LTO. Patients were divided into two groups according to age at operation (19 cases in group 1 aged ≥65 years and 30 cases in group 2 aged <65). Patients in a single group were regrouped into two subgroups according to preoperative Takakura stage (stage II + IIIA versus IIIB) to determine if the degree of correction varied in Takakura stage IIIB. ResultsSignificant changes in radiographic parameters were observed with no significant differences in the amounts of correction between groups 1 and 2. Comparison of Takakura stage II + IIIA in group 1 to that in group 2 and stage IIIB in group 1 to that in group 2 revealed no significant differences in the amounts of correction. ConclusionLTO could be indicated for patients over 65 years if patient selection was appropriate. LTO in patients over 65 years showed similar radiographic improvements to those in younger patients, and the correction was successfully maintained during the follow-up period. The correctional power of all radiographic parameters did not vary by preoperative Takakura stage. Level of EvidenceLevel III, comparative series

Treatment of Post Traumatic Asymmetrical Ankle Arthritis Using Low Tibial Osteotomy

Treatment of Post Traumatic Asymmetrical Ankle Arthritis Using Low Tibial Osteotomy

Intra- and Extra-Articular Deformity of Lower Limb: Tibial Condylar Valgus Osteotomy (TCVO) and Distal Tibial Oblique Osteotomy (DTOO) for Reconstruction of Joint Congruency.

Osteotomies are the established surgical procedure for the deformity of the lower limb induced by osteoarthritis (OA) of the knee and ankle. Closed-wedge (CW) and open-wedge (OW) high tibial osteotomy (HTO) are extra-articular surgery, which aim to shift the mechanical axis from medial to slightly lateral and reduce the overload in the medial compartment of the varus deformed knee by extra-articular correction. However, varus deformity of the knee with the teeter effect, which could be accompanied with subluxation and thrust due to the medial-lateral soft tissue imbalance, is not resolved only by the shift of mechanical axis. The depression of the medial tibia plateau, so-called pagoda deformity, is the intra-articular deformity, which could potentially cause the teeter effect and involves intra-articular incongruency. In such case, the osteotomy with novel concept should be developed to overcome the issues, both the imbalance of soft tissue and intra-articular deformity. Tibial condylar valgus osteotomy (TCVO) is an intra-articular osteotomy, which improves the joint congruency of the medial-compartment knee OA with subluxation and/or intra-articular deformity and also provides better joint stability. A similar argument is raised in the treatment of the ankle OA. Low tibial osteotomy (LTO) is an extra-articular surgery to correct malalignment of lower leg. Distal tibial oblique osteotomy (DTOO) is a novel surgery to improve the bony congruency of the ankle OA. In DTOO, the distal tibia is cut obliquely from the proximal medial to the distal lateral in the coronal plane and towards the center of the tibiofibular joint to improve the bony congruency of the ankle joint. Tibial condylar valgus osteotomy (TCVO) and distal tibial oblique osteotomy (DTOO) can correct intra-articular deformity of knee and ankle, respectively. The rationale and indication of TCVO and DTOO for the treatment of the lower limb by reconstructing the joint congruency are discussed.

Changes of hindfoot alignment after high or low tibial osteotomy

Category: Hindfoot Introduction/Purpose: We aimed to determine the change in hindfoot alignment after high (HTO) or low tibial osteotomy (LTO), which is commonly performed to prevent the progression of arthritis of the knee or ankle. Methods: We retrospectively reviewed the radiographic findings of patients who underwent HTO or LTO for arthritis with varus deformity of the knee or ankle joint. The hindfoot alignment view angle (HAVA), hindfoot alignment ratio (HAR), and hindfoot moment arm (HMA) were measured using the hindfoot alignment radiographs. All radiographic parameters were measured at 3, 6, and 12 months postoperatively to assess serial changes. Results: In the HTO group, the HAVA and HMA were significantly increased at 12 months postoperatively compared to preoperatively (P=0.03 and 0.001, respectively). Similarly, the HAR increased from 0.23 preoperatively to 0.44 at 12 months postoperatively, which was a statistically significant change (P=0.001). In the LTO group, the 12-month postoperative HAVA, HAR, and HMA were significantly decreased (P=0.001 for each), which represented a hindfoot alignment change to the valgus position. Conclusion: After HTO, preoperative hindfoot valgus deviation was significantly decreased at 12 months and approached normal values, while the preoperative mild hindfoot varus alignment was changed to valgus deviation after LTO.

Clinical comparison of ankle arthrodesis with distal tibial oblique osteotomy for the patient with stage 3b ankle arthritis

Category: Ankle Arthritis Introduction/Purpose: Ankle arthrodesis (AA) has been applied for end-stage ankle arthritis. On the other hand, low tibial osteotomy has been applied for mild to moderate ankle arthritis, however distal tibial oblique osteotomy (DTOO) has come to be applied for end-stage arthritis and clinical results were reported to be favorable. The purpose of this study was to compare clinical outcomes after AA and DTOO. Methods: From 2011 to 2014, 37 patients with stage 3b ankle arthritis were treated surgically. In these patients, 25 whose talar tilting angle (TTW) was over 10 degrees with minimum follow-up of 1 year were investigated in this study. Seventeen patients were treated by AA and 8 were treated by DTOO. Clinical outcomes were assessed using the Japanese Society for Surgery of the Foot (JSSF) ankle/hindfoot scale before surgery and at the latest follow up. The patient-based evaluation was performed at the latest follow up using Self-administered evaluation questionnaire (SAFE-Q). TTW and range of motion (ROM) of the ankle were also evaluated before surgery and at the latest follow up. In addition, rate of bony union and complications were investigated. Results: The average ages at the surgery were 60(41-77) years old in the AA group and 66(49-75) in the DTOO group. The average follow up periods were 32(15-49) months in the AA group and 29(13-52) in the DTOO group. Scores of the JSSF scale significantly improved at the latest follow up in both groups. In comparison between two groups, “Social functioning” and “General Health and Well-being” scores in SAFE-Q were significantly higher in the AA group than in the DTOO group. In contrast, ROM was higher in the DTOO group than in the AA group. There were no significant differences in TTW, bony union rate and complications. Conclusion: Ankle arthrodesis spoils the joint motion, however it restores stability and activity of the daily living, that leads to the higher levels of social functioning, general health and well-being.

Changes in Hindfoot Alignment After High or Low Tibial Osteotomy

We aimed to determine the change in hindfoot alignment after high (HTO) or low tibial osteotomy (LTO), which is commonly performed to prevent the progression of arthritis of the knee or ankle. We retrospectively reviewed the radiographic findings of patients who underwent HTO or LTO for arthritis with varus deformity of the knee or ankle joint. The hindfoot alignment view angle (HAVA), hindfoot alignment ratio (HAR), and hindfoot moment arm (HMA) were measured using the hindfoot alignment radiographs. All radiographic parameters were measured at 3, 6, and 12 months postoperatively to assess serial changes. In the HTO group, the HAVA and HMA were significantly increased at 12 months postoperatively compared to preoperatively ( P = .03 and .001, respectively). Similarly, the HAR increased from 0.23 preoperatively to 0.44 at 12 months postoperatively, which was a statistically significant change ( P = .001). In the LTO group, the 12-month postoperative HAVA, HAR, and HMA were significantly decreased ( P = .001 for each), which represented a hindfoot alignment change to the valgus position. After HTO, preoperative hindfoot valgus deviation was significantly decreased at 12 months and approached normal values, while the preoperative mild hindfoot varus alignment was changed to valgus deviation after LTO. Level III, comparative series.

Endoscopic Adhesiolysis of Flexor Hallucis Longus Muscle

Adhesion of the flexor hallucis longus (FHL) muscle to the distal tibia can occur after distal tibial fracture, distal fibular fracture, low tibial osteotomy, soft-tissue injury at the posterior ankle, subclinical compartment syndrome of the distal deep posterior compartment of the leg, or Volkmann contracture after deep posterior compartment syndrome of the leg. The purpose of this Technical Note is to report the endoscopic approach of FHL muscle adhesiolysis. It is indicated in patients with symptomatic adhesion of the FHL muscle and contraindicated if there is entrapment of the FHL muscle or tendon in the fracture callus or if there is extensive fibrosis and contracture of the FHL muscle as a result of Volkmann contracture after deep posterior compartment syndrome of the leg.

Long-Term Results Of Low Tibial Osteotomy For Ankle Osteoarthritis

Category: Ankle Arthritis Introduction/Purpose: There are not many reports about long-term results of low tibial osteotomy (LTO) for ankle osteoarthritis. We mention treatment results for cases in which, among the cases where LTO was performed for ankle osteoarthritis caused by malalignment, tracking was possible for 10 years or more. Methods: The study evaluated 11 ankles of 11 patients. Among these were 1 male and 10 females, with a mean age of 57 years, and a mean observation period of 11 years, 5 months. There were 10 joints of 10 patients with varus type osteoarthritis, and 1 joint of 1 patient with valgus type osteoarthritis. For varus type osteoarthritis, in the Tanaka’s X-ray classification, there were 3 joints at stage 2, 2 joints at stage 3a, and 5 joints at stage 3b. As surgical procedures, LTO was performed for 3 joints, LTO with medial malleolar osteotomy was performed for 6 joints, LTO with reconstruction of collateral ligament was performed for 1 joint, and LTO with subtalar arthrodesis was performed for 1 joint. In the clinical evaluation, we used the score of Takakura et al, and in the postoperative radiographic evaluation, we used Tanaka’s X-ray classification. Results: Clinical results improved from a preoperative mean of 68.7 points to a one-year postoperative score of 77.2 points, with a score at final observation of 76.3 points. The postoperative radiographic evaluation one year after surgery was Stage 1 in 5 joints, and Stage 2 in 5 joints, but at the time of final observation, the results were Stage 1 in 3 joints, Stage 2 in 4 joints, Stage 3a in 1 joint and Stage 4 in 2 joints. The talar tilting angle had improved, from 9.6° preoperatively to 3.9° at the time of final observation. A strongly positive correlativity was seen between preoperative X-ray classification, arthroscopic classification and X- ray classification at the time of final observation. Conclusion: There are no doubt cases where the preoperative severity of the condition has an effect postoperatively, and in the long term, narrowing of the joint space progresses, with clinical results gradually falling, but that progression is gradual, so by performing LTO, it is believed to be possible to maintain functions that adequately tolerate the activities of daily living for that age.

Correlation Between the Talar Tilt Angle and Hindfoot Varus in Medial Ankle OA

Category: Ankle Arthritis Introduction/Purpose: Radiographically medial ankle osteoarthritis shows different features according to talar tilt which is known to an important determining factor in low tibial osteotomy surgery. However, little is known about the reason of this presentation. We hypothesized that the talar tilt angle and degree of hind foot varus might be correlated. Methods: We reviewed radiographs of 184 patients diagnosed with medial ankle osteoarthritis between May 2006 and February 2015. A total of 126 ankles in 97 patients diagnosed as Takakura stage 1–3b medial ankle osteoarthritis, were reviewed. We measured tibio-talar angle, talar tilt angle, tibial-anterior surface angle, and hindfoot alignment angle We divided the ankles into 4 groups according to tibio-talar angle by 10 degrees, and each group was further divided into 2 subgroups based on median talar tilt angle. We analyzed the correlation between talar tilt and hindfoot alignment angle in each group. We analyzed the differences in the hind foot alignment between the subgroups. Ankle radiographs of selected patients were measured by two observers to determine the interobserver reliability. One of the observers evaluated all radiographs twice to determine the intraobserver reliability. Results: The tibiotalar angle was strongly correlated with the talar tilt angle (r=−0.845), while there was no correlation between tibio-talar angle and hindfoot alignment angle(r=-0.595). Among the groups, tibio-talar angle of 70-80 showed a significantly different hindfoot alignment between the 2 subgroups (p=0.0187). In the rest groups, there was no significant difference between tibio-talar and hindfoot alignment angle. The interobserver and intraobserver reliability for all radiographic measurements was good to excellent Conclusion: We could find out a definite correlation between talar tilt and hindfoot alignment angle in certain degree of varus ankle OA, and no correlation between tibio-talar angle and hindfoot alignment, which might have a clincal relevance in determining the method of osteotomy surgery.

The results of modified distraction arthroplasty for degenerated osteoarthritis of the ankle

Purpose: In the treatment of degenerated osteoarthritis of the ankle, we obtained good results in terms of preserving the joint functions and relieving pain by performing a procedure to reconstruct the anatomical structure of the ankle, accompanied by ROM exercises undertaken with the joint space kept pulled apart with a conventionally used external fixator. Methods: A total of 43 patients (45 ankles; 28 ankles in 28 male patients and 17 ankles in 15 female patients) who underwent the procedure from 1998 to 2012 were enrolled in the study. The patients were 18-72 years old, with a mean age of 56 years at the time of the procedure. In regard toTakakura’s classification, 6 ankles were classified as Stage 2, 21 as Stage 3a, 12 as Stage 3b, and 6 as Stage 4. The patients underwent debridement by the conventional method, including removal of bone spurs and synovectomy, combined with low tibial osteotomy, osteochondral graft, drilling and/or reconstruction of ankle lateral ligaments. As post-treatment, patients were started on active ROM exercises from the day after the surgery and started partial weight bearing at 6-8 weeks after the surgery. The external fixation device was removed to allow total weight bearing at 3 months. Follow-ups were performed for 1-8 years, with a mean of 4 years and 7 months. Results: The pain severity did not change in 2 ankles. For the remaining 43 ankles in which the pain improved, no problems in daily life activities, but inability to undertake sports activities were observed for 31 ankles, while no problems in either physical work or sporting activities for 12 ankles. None of the patients took painkiller. Improvements of the ROMwere seen in 10 ankles, while no change of the ROMwas observed in the remaining 35 ankles. There were no patients who needed additional operations such as arthrodesis during the follow-up period. Conclusions: Procedures such as arthrodesis, total ankle replacement and low tibial osteotomy are performed to treat degenerated osteoarthritis of the ankle, but each of these is associated with problems, including those related to the qualifying age, durability, and range of motion. It is difficult to select a proper treatment option, especially for relatively young patients. In contrast, there is no age requirement for the procedure described in this study, because joint functions are preserved by restoring the patients’ own tissue and the patients suffered only mild postoperative limitation of the ADL. As demerits, this procedure is less effective for pain relief than arthrodesis and more abundant experience is required, because several kinds of surgical procedures have to be performed. However, it can be indicated for young patients in whom preservation of the joint functions and higher activity potential are required. In addition it is well applicable to degenerated osteoarthritis of the ankle that arises at a relatively early age, because future joint replacement or arthrodesis will not be difficult in patients who undergo this procedure.

The use of the reconstruction plate in multiplanar tibial osteotomies in children

External fixation and cross-pin fixation appear to be the two most commonly used forms of fixation after a tibial osteotomy in children described in the literature. The purpose of this study is to describe our experience using a properly bent and contoured reconstruction plate for mismatched surfaces after a multiplanar tibial osteotomy. A retrospective review was conducted of 37 multiplanar tibial osteotomy surgeries in 23 children performed by a single surgeon using a reconstruction plate for internal fixation. A low fibular osteotomy and tibial osteotomy that required contouring and shaping of the plate were performed in all cases. A proximal tibial osteotomy was performed in 30 cases and a distal osteotomy in seven cases. All cases were reinforced with a long-leg cast. All charts were reviewed for intra- and postoperative complications. The surgery using the reconstruction plate internal fixation was considered to be a success if there was healing of the osteotomy and no hardware failure. A properly bent and contoured reconstruction plate conformed well to the mismatched surfaces after tibial osteotomy. Hardware was removed in all but two cases, on average 7months after surgery. There were no hardware failures. No child developed a deep wound infection or neurovascular complication, including compartment syndrome. Only two complications in 37 surgeries (5%) were encountered and were typical of any type of internal fixation. One child required an exploratory procedure because of screw extrusion and one child developed a post-plate removal fracture. The reconstruction plate is very malleable and can be contoured to fit in nearly every direction to accommodate mismatched appositional surfaces. It has been successfully employed in 37 consecutive cases of multiplanar tibial osteotomy in children with relatively few complications, none directly related to the plate.

Opening wedge low tibial osteotomy: A minimally invasive approach

Valgus osteotomy of the distal tibia may decrease the symptoms of ankle osteoarthritis and halt the progression of degeneration by redistributing or decreasing joint contact stress. Classically, opening wedge low tibial osteotomy was performed as an open procedure and the osteotomy site was stabilised by K wires or medial plates. Potential complication of the medial wound can be disastrous. Wound breakdown can lead to exposure of the implant. We present a minimally invasive approach with osteotomy and bone grafting through a small posteromedial wounds and the osteotomy site is stabilized with MIPO (minimally invasive plate osteosynthesis) technique. This approach can minimize the soft tissue dissection and the potential wound complication.

Low tibial osteotomy for varus-type osteoarthritis of the ankle

In this retrospective study we have assessed the results of low tibial valgus osteotomy for varus-type osteoarthritis of the ankle and its indications. We performed an opening wedge osteotomy in 25 women (26 ankles). The mean follow-up was for eight years and three months (2 years 3 months to 17 years 11 months). Of the 26 ankles, 19 showed excellent or good clinical results. Their mean scores for pain, walking, and activities of daily living were significantly improved but there was no change in the range of movement. In the ankles which were classified radiologically as stage 2 according to our own grading system, with narrowing of the medial joint space, and in 11 as stage 3a, with obliteration of the joint space at the medial malleolus only, the joint space recovered. In contrast, such recovery was seen in only two of 12 ankles classified as stage 3b, with obliteration of the joint space advancing to the upper surface of the dome of the talus. Low tibial osteotomy is indicated for varus-type osteoarthritis of stage 2 or stage 3a.