Corrective ankle osteotomies

Clin Podiatr Med Surg

21 (2004) 353–370

Corrective ankle osteotomies

Thomas S. Roukis, DPMWeil Foot and Ankle Institute, 1455 East Golf Road, Suite 131, Des Plaines, IL 60016, USA

Corrective osteotomies about the ankle involve the fibula, distal tibial meta-

physis (supramalleolar, supratalar, transmalleolar), or distal tibial metaphyseal-

diaphyseal junction (low tibia) and are indicated when angular, rotational, or

translational malalignment are present. The most common indication is malalign-

ment following a traumatic injury to the ankle malleoli or tibia. For example,

Nicoll [1] noted an 8.6% incidence of residual deformities (greater than

10-degree angulation in any plane, greater than 10-degree rotation, or greater

than 2-cm shortening) in a series of 671 tibial fractures. Additionally, Ellis [2]

noted a 6% incidence of limited ankle or foot motion in 343 tibial shaft fractures.

And McMaster [3] found a 72% incidence of limited subtalar motion in 100 tibial

fractures. Although debate exists over what degree of tibial, fibular, and ankle

malalignment is acceptable, most surgeons performing ankle and lower limb

deformity correction would agree that malalignment beyond 10 to 15 degrees in

any cardinal plane would be unacceptable and appropriate to consider for surgical

correction [4–7]. Several clinical and cadaveric studies have demonstrated an

increased incidence of ankle joint arthrosis and changes in the contact area of the

ankle joint following fibular and tibial angular deformities [8–10]. Frontal plane

(varus and valgus) malalignment of the tibia has been shown to be more readily

tolerated than sagittal plane malalignment (anterior bow or procurvatum and

posterior bow or recurvatum) due to the inherent frontal plane motion present

within the subtalar and midtarsal joints [8–14]. For the distal tibia, sagittal plane

deformities of 15 degrees have been shown to create a 40% decrease in contact

area, whereas frontal plane deformities of 15 degrees create a decrease of only

15% to 20% because of the compensation available within the subtalar and

midtarsal joints [8–12]. The level of the tibial malalignment deformity (proximal,

middle, or distal third) has been shown to affect the contact area of the ankle with

distal third (low tibia) deformities resulting in the greatest alteration (universally

0891-8422/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved.

doi:10.1016/j.cpm.2004.03.007

No funding of any kind was received by the author for this article. The author is a consultant for

Smith & Nephew Orthopaedics, Inc., external fixation section.

E-mail address: [email protected]

T.S. Roukis / Clin Podiatr Med Surg 21 (2004) 353–370354

greater than 10%) [8–12]. Finally, it is well accepted that fibular shortening,

lateral shift, and malrotation increases contact pressures of the ankle [15].

The goal of corrective ankle osteotomies is to reestablish normal triplanar

ankle joint alignment and the weight-bearing area of the ankle to a normal

anatomical relationship. The normal frontal plane alignment of the ankle (lateral

distal tibial angle) is 89 degrees (86 to 92 degrees), and the normal sagittal

plane alignment of the ankle (anterior distal tibial angle) is 80 degrees (78 to

82 degrees) [16–19]. These normal values are relative to the mechanical axis of

the tibia, which is a bisection of the medial and lateral, and anterior and posterior

cortices of the diaphyseal segment of the tibia, respectively. The mechanical axis

of the tibia should extend through the middle of the talar dome on an anterior-

posterior view and within 1 cm of the lateral process of the talus (center of ro-

tational axis of the ankle) on a lateral view [16–18].

Specific to the fibula, the accepted normal alignment is when (1) the entire

ankle joint possesses an equidistant and parallel joint space (no medial widening);

(2) Shenton’s line (subchondral contour of the distal tibial plafond and fibula) is a

curved, unbroken line; (3) an intact ‘‘Dime sign’’ (unbroken curve between the

lateral part of the articular surface of the talus and distal fibular recess) exists;

(4) talar tilt (lines drawn along the dome surface of the talus and distal tibial

plafond) is parallel or within 3 degrees of parallel; and (5) the medial clear space

(distance between the medial margin of the fibula and incisura fibularis of the dis-

tal tibia measured 1 cm above the distal tibial plafond) is less than 6 mm [20–22].

Fibular osteotomies

Weber B and C fibular fractures, especially those with comminution and syn-

desmotic disruption, can result in fibular shortening and malrotation unless

special attention is paid to preservation of the ligamentous soft-tissue envelope

and distraction methods to regain length are employed at the time of the index

surgical reduction [20–22]. Malreduced fibular fractures and associated abnor-

malities of talar position within the ankle mortise can usually be fully assessed on

plain film radiographs. A comparison of the injured ankle to the contralateral,

uninvolved ankle and the established range of accepted values described above

should expose a grossly abnormal degree of fibular shortening and lateral trans-

lation. However, fibular rotational malalignment is much more difficult to

accurately determine on plane film radiographs. When rotational malalignment

is suspected, the use of CT scanning with three-dimensional reconstruction

should be considered. Assuming no metallic implants about the ankle joint, the

use of MRI has the added benefit of articular cartilage assessment. The degree of

articular degeneration is an important factor in determining whether to perform a

corrective fibular osteotomy in an attempt to decrease the painful symptoms and

slow or stop the progression of further arthrosis (mild to moderate disease) or to

perform a well-aligned ankle arthrodesis or implant arthroplasty (advanced or

end-stage disease).

T.S. Roukis / Clin Podiatr Med Surg 21 (2004) 353–370 355

The surgical technique itself begins with the patient positioned supine on the

operating room table with a large, well-padded bolster beneath the buttock to

control physiological external rotation of the lower leg. Because most corrective

fibular osteotomies are performed following previous surgical intervention with

associated soft tissue and musculotendinous scarring and contractures, the author

prefers to have the patient under general anesthesia and fully paralyzed to fa-

cilitate complete correction of the fibular deformity. Because a thigh tourniquet is

usually necessary for hemostasis, this method of anesthesia also minimizes the

time-related tourniquet pain issues frequently encountered with either spinal

anesthesia or local anesthesia infiltration with intravenous sedation.

Under tourniquet control, the distal fibula is exposed through a lateral lon-

gitudinal incision that is either directly through any previous incision or slightly

biased to the posterior border of the fibula along its length. The author prefers to

bias the incision slightly toward the posterior border of the fibula so that if any

wound healing complications arise, the peroneal musculature can be advanced

over the wound and a simple split-thickness skin graft applied. The lower third of

the leg and ankle region are notoriously difficult to cover with local cutaneous or

muscular flaps, and it is better to plan ahead for a potential wound healing com-

plication during the secondary surgical reconstruction with careful incision

planning than to deal with exposed hardware and bone stripped of its periosteum

postoperatively. The incision is kept full thickness and deepened directly to the

level of periosteum in a controlled fashion (Fig. 1A). The periosteum is then

incised along the entire course of the fibula with the most exposure being over the

anterior portion of the fibula to free the interosseous membrane (tibial-fibular

syndesmosis). The author prefers to perform the greatest degree of interosseous

membrane dissection distal to the proposed osteotomy with the use of a sharp

periosteal elevator and then to simply perforate the remainder with a no. 11 blade

to create some laxity in these dense tissues but still maintain their integrity. This

is an important consideration because complete stripping of the entire interosse-

ous membrane can lead to a lateral bowing of the fibula upon attempted distrac-

tion, rather than pure lengthening. If lateral bowing of the fibula is encountered, it

will be necessary to use multiple transsyndesmotic screw fixation to maintain

alignment and prevent secondary deformity. Any retained hardware is removed in

as atraumatic a fashion as possible with great care taken to preserve the entire soft

tissue and ligamentous envelope if possible. The level of osteotomy should be

within the distal one third of the fibula and specifically within a 4-cm interval

above the level of the distal articulation between the tibia and fibula [20–22]. It is

imperative to remove any osteophyte formation or scar tissue interposition be-

tween the medial shoulder of the talus and medial malleolus to be able to fully

restore the talus to its original position following fibular lengthening. This can be

accomplished through either an arthroscopic debridement, which has the added

benefit of full documentation and potential restoration of any articular derange-

ment, or a mini-arthrotomy technique. Additionally, if the fibula is malrotated, it

will be necessary to debride the interval between the tibia and fibula to correct the

malrotation. Under direct image intensification, a transverse osteotomy is created


with an osteotome and mallet rather than power instrumentation to avoid heat

necrosis of the bone ends. The lower leg is then suspended on several sterile

towels, which should be just proximal to the osteotomy to allow the weight of the

foot and ankle to distract the osteotomy enough to insert a minilaminar spreader

and allow for physiologic posterior translation of the talus within the ankle

mortise. The minilaminar spreader is then slowly dialed open while the assistant

holds the foot and ankle at 90 degrees to one another until the desired amount of

length and rotation are achieved, with care taken to make certain that the talus is

not inadvertently displaced anteriorly during these maneuvers (Fig. 1B).

The benefit of a transverse osteotomy over a Z-shaped or oblique osteotomy is

that a significant amount of length can be achieved and a greater ability to correct

Fig. 1. (A) The lateral aspect of the fibula is exposed following removal of a retained plate and screws.

Note the limited dissection about the fibula and preservation of most of the interosseous membrane

throughout. (B) The proximal lower leg has been suspended on a bolster of towels, and the laminar

spreader has been dialed open to the desired amount of length for full correction of the fibular

deformity. Note the surgical assistant maintaining the ankle joint reduced with manual traction. (C) A

posterior plate and screws has been applied with the fibula held in distraction. Note the autogenous

cancellous bone graft held within the forceps, which has been harvested from the calcaneus through

the small incision shown on the lateral aspect of the calcaneus. (D) The autogenous cancellous bone

graft has been packed within the osteotomy defect revealing no gapping whatever.

Fig. 1 (continued).


for any concomitant rotational malalignment exists [20–22]. The use of an

external fixator may be used to slowly ‘‘dial in’’ the desired amount of length

instead of the laminar spreader but cannot fully correct rotational malalignment

because of the fixed nature of the transfixion pins and, therefore, is not routinely

used by the author [20–22]. A low-profile, well-contoured plate is then applied

with the fibula held in its corrected position. After all appropriate screw holes have

been filled, the laminar spreader is removed (Fig. 1C). The resultant osseous

defect is then packed with autogenous bone graft most commonly harvested from

the calcaneus or proximal tibial metaphysis and gently tamped into place (Fig. 1D).

If possible, regional muscle is advanced over the bone graft and sutured to the

surrounding ligamentous tissues and fascia to enhance its vascular supply and

osseous incorporation. Although not routinely used, the use of platelet-rich plasma

(GPS, Cell Factor Technologies, Biomet Orthopedics, Inc., Warsaw, IN) can be

mixed with the harvested bone graft and a dermal ‘‘graft jacket’’ (Wright Medical

Technology, Arlington, TN) or a cadaveric fascia lata graft employed to encircle


the bone graft. In the author’s experience, these specialized techniques seem to

enhance primary incorporation and minimize migration of the bone graft,

respectively. The surgical site is irrigated and closed in layers with the skin edges

loosely approximated to allow for bloody drainage to escape rather than collect

deep within the wound and create a hematoma. Alternatively, a suction drain can

be employed and removed once the total output is less than 1 cc/h. Awell-padded,

short-leg sugar-tong splint is applied with the foot and ankle held at 90 degrees to

one another and converted to a short-leg non–weight-bearing cast 5 to 7 days

postoperative to allow the initial edema to subside. The cast is changed at regular

intervals and converted to a walking cast or removable walker once osseous

consolidation has sufficiently developed, which is usually within 6 to 8 weeks of

the secondary surgical reconstruction. An aggressive physical therapy program is

then initiated to reduce edema, increase ankle motion, and regain strength and

proprioception. An athletic brace will frequently be needed for several months

following full rehabilitation to prevent late collapse. If necessary, the internal

fixation may be removed after 6 to 12 months time.

Distal tibial metaphyseal osteotomies (supramalleolar, supratalar,

transmalleolar)

Severe ankle fracture-dislocations with medial and posterior malleolar in-

volvement will frequently lead to varus malalignment secondary to proximal

migration of the medial malleolus and procurvatum malalignment as a result of

proximal migration of the posterior malleolus, respectively [23–27]. Valgus

malalignment of the ankle is most frequently encountered with severe end-stage

posterior tibial tendon dysfunction secondary to progressive collapse of the lateral

aspect of the distal tibial metaphysis and to a lesser extent stress fracture of the

fibula [28]. However, other nontraumatic etiologies are possible [29–31]. An

intraarticular pilon-type fracture can create a deformity in any plane as a result of

the extensive metaphyseal involvement particular to this severe crush-type injury

[32–34]. Significant rotational deformities do not usually develop following

trauma but must be carefully assessed in the presence of neuromuscular and

congenital deformities [35–37].

As described above for fibular osteotomies, a comparison of the injured ankle

to the contralateral, uninvolved ankle and the established range of accepted

values described above should expose a grossly abnormal degree of distal tibial

metaphyseal malalignment. Specific to frontal plane deformities, it is essential to

include an axial calcaneal view of both feet to evaluate for any structural de-

formity within the calcaneus that could either enhance or be responsible for the

frontal plane malalignment of the ankle [11]. As described for the fibula, ro-

tational malalignment is much more difficult to accurately determine on plain-

film radiographs. When rotational malalignment is suspected, the use of CT

scanning or MRI with three-dimensional reconstruction should be considered for

the same reasons previously described. Because most distal tibial metaphyseal


malalignment deformities develop following a significant traumatic injury, the

use of enhanced image techniques also allows full evaluation of any potential for

a sterile or septic nonunion. If a sterile nonunion is encountered, consideration

should be given to realignment and open autogenous bone grafting mixed with a

platelet concentrate (GPS, Cell Factor Technologies, Biomet Orthopedics, Inc.)

and internal bone growth stimulation (Osteogen, EBI Medical, Biomet Orthope-

dics, Inc.), preferably using a minimally invasive locking-plate technique

(Synthes USA, Paoli, PA) or alternatively an Ilizarov external ring fixation

system (Smith & Nephew, Inc., Memphis, TN), which has the added benefit of

partial weight-bearing assisted ambulation. However, if a septic nonunion is

encountered, further work-up with the use of contrast-enhanced imaging and

nuclear medicine studies are obviously warranted. Surgical treatment will need to

be staged and usually consists of either resection, antibiotic-loaded bone cement

spacing and late autogenous bone block arthrodesis, or less commonly, delayed

distraction arthrodesis using the Ilizarov external fixation system alone or over a

retrograde intramedullary distally locked nail [38,39]. The benefit of the intra-

medullary nail is that it allows for direct linear lengthening and the ability to

correct for any rotational malalignment as well as a structurally sound arthrodesis

site with the continued ability to allow partial assisted weight-bearing once the

proximal locking screws are placed at the time or external fixation removal [40].

The surgical technique begins in the same manner as for the fibular osteotomy

described above with the patient positioned supine on the operating room table

with a large, well-padded bolster beneath the buttock to control physiological

external rotation of the lower leg. Once again, the author prefers to have the

patient under general anesthesia and fully paralyzed with a thigh tourniquet and

the entire lower leg prepped out above the knee. It is essential to have the entire

lower leg prepped out to evaluate the foot, ankle, and lower leg relationship,

which can only happen if the knee and proximal tibia are fully exposed and

readily visualized. Any concomitant procedures about the ankle and lower leg are

performed before the actual distal tibial metaphyseal osteotomy to limit the

amount of manipulation and associated neurovascular irritation or frank violation.

Examples include tendoachilles lengthening; removal of retained internal fixation

about the ankle; arthroscopic ankle debridement with or without anterior tibial

and talar exostectomy; and hindfoot osteotomies or arthrodesis procedures. Once

these ancillary procedures have been completed and properly stabilized, the hip

bolster is removed to allow for full appreciation of the ankle malalignment. The

lower leg is then elevated on a stack of sterile towels and placed on an image

intensifier with the distal tibia and ankle fully visualized. A percutaneous

osteotomy is then performed at the level of the deformity using hand instrumen-

tation if possible to avoid any thermal necrosis associated with power instru-

mentation as well as to allow optimal osteotomy precision and control [41].

The author prefers to perform a focal dome or crescentic-shaped osteotomy

[42] whenever internal fixation is to be the fixation method and a transverse

osteotomy whenever external fixation with subsequent distraction osteogenesis

[25,43,44] is to be the fixation method employed. The decision-making process


for whether to use acute correction with internal fixation or gradual correction

with external fixation depends on the degree of correction necessary, potential

tension on neighboring structures at risk (neurovascular bundles), and, to a lesser

extent, the surgeon’s preference [44]. If the deformity is to be corrected acutely, a

focal dome osteotomy will allow for triplane correction of the deformity while

limiting the amount of osseous shortening [42]. A 1- to 2-cm incision is made

longitudinally at the level of the deformity at the medial aspect of the lower leg

and a series of drill holes are made in a crescentic shape (usually with a proximal

apex) using a 2.7-mm drill bit. The author has modified a sterile light handle with

multiple drill holes circumferentially about the outer handle to create a template

for this osteotomy. This is an inexpensive and reusable device that works well in

the author’s hands. The use of a Rancho cube from the Ilizarov external fixation

system (Smith & Nephew, Inc.) can also be used but seems to be more labor

intensive (personal communication, Robert Mendicino, DPM, February 2004).

Once the drill holes have been completed under direct image intensification, a

small gouge or curved osteotome is used to perforate the areas between the drill

holes. The osteotomy is then gently manipulated in all three cardinal planes to

verify complete separation of the two osseous segments. The foot and ankle are

then acutely manipulated to realign the distal and proximal osseous segments the

desired degree of correction and provisionally fixated with small diameter Kirsch-

ner wires. The osteotomy is then fixated with either large diameter crossing

screws, plates, or with an external fixation system. The author prefers to fixate

these osteotomies with a less invasive stabilization system (LISS) technique using

a locking plate (Synthes). Because the procedure is performed percutaneously,

dissection is kept to a minimum, and because the plates used are a locking design,

there is no specific need to obtain bicortical screw purchase. This technique has

the added benefit of allowing early, controlled physical therapy and partial

assisted weight-bearing as appropriate. Depending on the patient’s motivation,

pain control, and morphology, cast immobilization can range from 2 to 6 weeks

followed by a removable walking cast for an additional 2 to 6 weeks. This is

followed, or performed concomitantly with, physical therapy to reduce edema,

stiffness, weakness, and pain.

If gradual correction is deemed the most appropriate, a 1-cm incision is made

at the level of the deformity, and a thin Kirschner wire is placed at the level of the

proposed osteotomy from medial to lateral under direct image intensification con-

trol. The osteotomy is performed with an osteotome and mallet, with care taken to

avoid excessive movements about the neurovascular bundle. The osteotomy is

then completed by placing the osteotome as deep as possible across the os-

teotomy and turning the osteotome 90 degrees. This technique will create a pal-

pable and audible ‘‘pop,’’ indicating completion of the osteotomy. A Gigli saw

may be used to perform the osteotomy as well, but the author has noticed in-

advertent damage to the soft tissue envelope (skin and musculotendinous

structures) as well as difficulty fully controlling the actual course of the os-

teotomy despite proper technique and attention to detail [41]. Once the osteotomy

is completed, the distal fragment is then manipulated in all three cardinal planes


to once again verify completion of the osteotomy. Although acute correction fol-

lowing a transverse osteotomy is possible, this technique requires bone grafting

with an opening wedge procedure followed by plate fixation and can result in

excessive lengthening with potential neurovascular compromise [24,26,27,42].

A closing wedge osteotomy is an alternative but results in shortening of the

osseous segment, which may of may not be desirable followed by either crossed

screw or plate fixation [26,27,42]. The greatest problem with an acute correction

using a transverse osteotomy is that translation of the distal segment readily

occurs and in most cases about the ankle results in potential compromise of the

medial neurovascular bundle and a prominent osseous bulge [43]. For these

reasons, whenever the author performs a transverse osteotomy, the correction is

produced gradually through distraction osteogenesis using the Ilizarov-Taylor

spatial frame external ring fixation system (Smith & Nephew, Inc.). This is a

highly sophisticated technique that employs six struts and a computerized

program to gradually correct the deformity based upon a number of coordinates

and reference markers, the specifics of which are beyond the scope of this article.

The use of hinges, posts, and telescopic rods from the traditional Ilizarov set may

be used instead but is much more labor intensive and adds a significant increase

to the cost of the external ring fixation system. The Ilizarov external ring fixation

system is preassembled the morning of surgery and tailored to the patient’s

specific anatomy. Following completion of the osteotomy, the external fixator

is placed over the lower leg and the proximal fixation ring block (two rings

connected by threaded rods or sockets) is stabilized using tensioned crossed wires

through appropriate anatomical corridors. The lower leg should now be firmed

anchored coaxial within the proximal fixation block. That is, image intensifica-

tion and clinical examination should verify a perpendicular relationship between

the horizontal rings and proximal osseous segment of the lower leg on an an-

terior-posterior view, and a parallel relationship between the threaded rods or

sockets connecting the fixation ring block and the proximal lower leg on a lateral

view. Once this has been verified, the distal fixation block is manipulated over the

distal osseous fragment to lie coaxial to the distal tibial plafond and ankle joint.

That is, image intensification and clinical examination should verify a perpen-

dicular relationship between the horizontal rings and distal tibial plafond of

the ankle joint on an anterior-posterior view, and a parallel relationship between

the threaded rods or sockets connecting the fixation ring block and the medial

malleolus on a lateral view. Multiple crossed thin wires with or, less commonly,

without an olive component are then placed across the distal osseous segment

through the appropriate anatomical corridors. The osteotomy is then compressed

into direct osseous apposition. Following an initial latency of between 7 and

10 days to allow for early osseous incorporation to occur, the osteotomy is gradu-

ally corrected the desired amount in all three cardinal planes at a rate of approxi-

mately 1 mm per day, according the computer program protocol [45]. Once the

deformity is fully corrected and the osseous regenerate mature, the external

fixation system can be removed (Fig. 2). The author prefers to remove the

external fixation system with the patient under general anesthesia to allow for a

Fig. 2. (A) Anterior-posterior and (B) lateral views immediately following a transverse distal tibial

metaphyseal osteotomy (with fibular osteotomy slightly proximal) using the Ilizarov-Taylor spatial

frame for a posttraumatic distal tibial metaphyseal varus malalignment. (C) Anterior-posterior and

(D) lateral views immediately before external fixation removal. Note the complete correction of the

varus malalignment as seen on the anterior-posterior view and intentional posterior translation of the

distal fragment as seen on the lateral view to properly align the lateral process of the talus directly in

line with the mechanical axis of the tibia.


timely removal without having to worry about startling and hurting the patient

with an in-office removal. More importantly, it allows a stress exam to be

performed to assess the integrity of the osseous regenerate through clinical and

image intensification analysis. If any motion is present, the author will percuta-

neously stabilize the osteotomy and osseous regenerate with multiple crossed large

diameter screws followed by short-leg cast application for 2 to 3 weeks and then

by a removable walking cast for an additional 2 to 3 weeks. This is followed, or


performed concomitantly with, physical therapy to reduce edema, stiffness, weak-

ness, and pain.

Distal tibial metaphyseal-diaphyseal osteotomy (low tibia)

Fractures about the distal third of the tibia, whether treated conservatively with

open/percutaneous internal plating or with proximal intramedullary nailing, can

result in a malalignment deformity [46–48]. A residual recurvatum deformity is

the most commonly encountered problem following plate fixation as the as-

sociated frontal plane and rotational malalignment deformities are usually easily

visualized and corrected at the time of the index surgery (Fig. 3) [46]. However,

combined varus malalignment and external rotation deformities are the most

commonly encountered problems following proximal intramedullary nailing [47]

because they are exceedingly difficult to correct regardless of the reduction tech-

nique employed (eg, tourniquet application about the fracture, calcaneal trans-

fixion pin weighted distraction, provisional external fixation) (Fig. 4) [49].

As described above for distal tibial metaphyseal osteotomies, a comparison of

the injured ankle to the contralateral, uninvolved ankle and the established range

of accepted values described above should expose a grossly abnormal degree of

distal tibial metaphyseal-diaphyseal malalignment. It is important to obtain an

axial calcaneal view of both feet to evaluate for any structural deformity within

the calcaneus that could enhance any frontal plane malalignment of the ankle. As

Fig. 3. (A) Anterior-posterior and (B) lateral views following an open reduction and internal fixation of

a distal third tibial fracture. Note that the anterior-posterior view demonstrates anatomic alignment, but

the lateral view clearly demonstrates a significant posterior bow or recurvatum deformity and

associated ankle, subtalar, and midtarsal joint arthrosis.

Fig. 4. (A) Anterior-posterior and (B) lateral views following a proximal intramedullary nailing of a

distal third tibial fracture. Note that the anterior-posterior view clearly demonstrates a varus

malalignment, and the lateral view clearly demonstrates an anterior bow or procurvatum deformity.


described above, rotational malalignment is much more difficult to accurately

determine on plain film radiographs. When rotational malalignment is suspected,

the use of CT scanning or MRI with three-dimensional reconstruction should be

considered for the same reasons previously described. Because most distal tibial

metaphyseal-diaphyseal malalignment deformities develop following a signifi-

cant traumatic injury, the use of enhanced imaging techniques also allows full

evaluation of any potential for a sterile or septic nonunion with the specific

treatments being similar to those for distal tibial metaphyseal malalignment

described above. If the deformity is appreciated early in the postoperative re-

covery period, it is usually possible to salvage the ankle joint because the in-

volvement is proximal to the level of malalignment and the degree of articular

damage should be minimal. However, it is more common to have a patient

present after a lengthy period of failed conservative management (eg, shoe modi-

fications, bracing), limited surgical intervention (eg, hardware removal, ankle

arthroscopy, or exostectomy), and, all too often, extended narcotic use for on-

going pain management. In these situations, the articular cartilage damage to the

ankle, subtalar, and midtarsal joints is usually significant and the author prefers to

perform a realignment of the lower leg at the level of the deformity and a tibial-

talocalcaneal (TCC) arthrodesis [49–51] as a salvage procedure before a

definitive below-knee amputation. These deformities are severely painful, debili-

tating, and frequently life-altering [52–54]. Proper counseling on more than one

occasion and with immediate family members present to weigh the pros and cons

of a limb salvage attempt, including the expected lengthy recovery course, in-

ability to resolve deep muscle scarring and neuritic pain components, and the

significant cost associated is essential and cannot be overstated. Awell-performed


below-knee amputation with a properly fit prosthesis is an excellent procedure

compared with living with a chronically painful and deformed lower leg and

avoids the old adage of ‘‘saving the leg but ignoring the person attached to

the leg.’’

The surgical technique begins in the same manner as for the distal tibial

metaphyseal osteotomy with the patient positioned supine on the operating room

table with a large, well-padded bolster beneath the buttock to control physiologi-

cal external rotation of the lower leg. Once again, the author prefers to have the

patient under general anesthesia and fully paralyzed with a thigh tourniquet and

the entire lower leg prepped out above the knee for the reasons described above.

Because this type of osteotomy is most commonly combined with a TTC arthro-

desis, this portion of the procedure is performed immediately following removal

of any retained hardware but before performing the actual distal tibial metaphy-

seal-diaphyseal osteotomy. The author prefers to employ a traditional medial

ankle arthrotomy and extensile lateral incision with resection of the fibula to

prepare the ankle and subtalar joints for later arthrodesis. The author’s approach

is to morselize the fibula and mix the results autogenous bone chips with al-

logenic bone and a platelet concentrate (GPS, Cell Factor Technologies, Biomet

Orthopedics, Inc.). This technique results in a thick, malleable bone paste that is

not easily displaced during irrigation, readily fills any osseous voids encountered,

and retains a high degree of osteoconductive and osteoinductive properties. Once

the ankle and subtalar joints have been prepared, the hip bolster is removed to

allow for full realignment and optimal positioning of the TTC arthrodesis.

Specifically, the calcaneus and talus are medially displaced to allow for proper

placement of the guide wire through the junction between the middle and pos-

terior facets of the subtalar joint and the middle of the talar body on the anterior-

posterior and lateral views obtained from the image intensifier. The guide wire for

the retrograde intramedullary nail is then placed according to the above-defined

anatomical reference points and advanced across the distal tibia to a point just

distal to the proposed osteotomy. The author has employed a distally based focal

dome osteotomy, which is performed and completed as described above for the

distal tibial metaphysis with the exception of a distal rather than proximal apex.

The apex of the osteotomy is reversed to allow proper placement of the proximal

locking screws for the retrograde intramedullary nail to have enough bone to

create a solid purchase (Fig. 5). If the apex was proximally based, the distal

locking screw would lie too close to the distal osseous segment and compromise

the stability of the fixation construct.

Once the osteotomy has been verified to be complete using the techniques

described above, the distal fragment is manipulated into a fully corrected position

and the guide wire for the retrograde intramedullary nail is advanced proximally.

The sequence of surgical steps specific to the retrograde intramedullary nail

employed is then performed and the appropriate length nail inserted after packing

the osteotomy and TTC arthrodesis sites with the premixed bone graft mixture

described above. The author prefers to use the Revision nail system (Smith &

Nephew, Inc.)—a third-generation retrograde intramedullary nail—because of its

Fig. 5. (A) A distally based focal dome osteotomy has been created using multiple drill holes with a

2.7-mm drill bit. (B) A gouge osteotome is seen imbedded between two drill holes in line with the

curvature of the osteotomy. (C) The focal dome osteotomy has been completed and verified with

distraction and gentle manipulation in all three cardinal planes.



simple technique, reliable equipment, stability, and time-honored longevity. Ad-

ditionally, a dual lead internal bone growth stimulator (Osteogen, EBI Medical,

Biomet Orthopedics, Inc.) is universally employed. Because this surgical inter-

vention is usually the last one before a below-knee amputation, the cost as-

sociated with an internal bone growth stimulator is well accepted by insurance

carriers and in the author’s hands has invariably resulted in a solid TTC ar-

throdesis and fully healed distal tibial metaphyseal-diaphyseal osteotomy. An

Ilizarov external ring fixation system (Smith & Nephew, Inc.) is then applied to

the lower leg, incorporating the foot. The external fixation system allows either

acute or gradual derotation of any compensatory forefoot/midfoot frontal plane

deformities either through simple soft tissue manipulation or following a per-

cutaneous midfoot osteotomy with a Gigli saw or osteotome and mallet [41].

Through the use of an arched wire technique (distal displacement of the midtarsal

transfixion wires followed by appropriate tensioning), an arthrodiastasis of the

talonavicular and calcaneal-cuboid joints is easily performed and has the potential

to limit postoperative stiffness and associated arthritic changes commonly

encountered in the midtarsal joints following a TTC arthrodesis. The use of the

Ilizarov external ring fixation system also allows early partial assisted weight-

bearing. The external fixation system is removed after 6 to 10 weeks once

osseous consolidation is evident (Fig. 6). At this time a short leg walking cast is

applied for 2 to 3 weeks and converted to a removable walking cast for an

additional 2 to 3 weeks. Aggressive physical therapy is employed to decrease

Fig. 6. (A) Anterior-posterior and (B) lateral views following a distal tibial metaphyseal-diaphyseal

focal dome osteotomy and TTC arthrodesis fixated with a locked retrograde intramedullary nail and

Ilizarov external ring fixation system. Note the use of a dual lead internal bone growth stimulator

about the osteotomy and arthrodesis sites. This is the same patient as shown in Fig. 3, indicating the

degree of correction achieved with this combined technique.


edema, stiffness, weakness, and pain. The use of a rocker-sole modification to

high-top work-type boots or athletic shoes with an ankle brace are used for an

extended period of time.

Following each of the procedures described above, the use of incentive

spirometry, enteric-coated full-dose aspirin, ‘‘bed exercise’’ (leg lifts and range

of motion several times each hour), and partial assisted weight-bearing is

routinely employed and enforced by the author to limit the incidence of a deep

venous thrombosis in those that do not have a significant number of risk factors.

The use of formal anticoagulation therapy should be employed in any patient with

additional risk factors beyond those inherent to the type of surgery described

above (tourniquet time, immobilization, major arthrodesis, or osteotomy).

Summary

The use of corrective ankle osteotomies of the fibula, distal tibial metaphysis,

or distal tibial metaphyseal-diaphyseal junction has been discussed in detail. The

author has presented a review of the literature and in-depth surgical technique for

each procedure as well as a review of how to prevent and address the most

common complications encountered. Specific attention should be paid to the

potential for developing a deep venous thrombosis and appropriate measures

undertaken to minimize their occurrence.

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Corrective ankle osteotomies