Video summary

Supramalleolar Osteotomy - BOFAS Master Techniques

Main summary

Key takeaways

Educational

Main ideas / lessons conveyed

  • Supramalleolar osteotomy (SMO) is presented as an important joint-preserving option for ankle osteoarthritis (OA) with frontal plane deformities (especially varus and valgus).
  • The goals of SMO are:
    • Realignment to correct abnormal loading (redistribute eccentric overload)
    • Pain relief and functional improvement
    • Slowing degenerative progression
    • Buying time before later total ankle arthroplasty (TAR) or ankle arthrodesis (fusion)
    • It can also act as a preparatory stage before future joint-sacrificing procedures.
  • The talk stresses appropriate staging/indication, referencing Takakura classification (stage 1–4):
    • SMO is generally aimed at Takakura stage 2 to 3A
    • Stage 3B is described as borderline / less predictable
    • Stage 4 is described as not an indication
  • Long-term expectations are framed as time-saving, not permanent cure:
    • Reported average ~88% survival around 5–5+ years (per cited literature)
    • Examples of 10–15 year good outcomes exist, but patients should be informed that future procedures (fusion or replacement) may be needed.
  • Overcorrection is discouraged beyond a modest range:
    • Literature suggests >4–5° overcorrection has no positive influence and may be harmful.
  • Radiographic/3D planning accuracy matters:
    • 2D measurements may be unreliable for some patients
    • CT with 3D reconstruction can provide more reliable angles and planning
  • SMO technique must account for:
    • Hinge screw use to protect the lateral hinge during medial opening wedge procedures
    • Choice of osteotomy type (opening wedge, closing wedge, dome) based on deformity magnitude
    • Concurrent hindfoot/subtalar and soft-tissue issues—because incomplete correction elsewhere can cause loss of correction or persistent symptoms.
  • The session provides practical “decision logic” for deformity and surgical planning.

Methodology / decision framework

1) Indications (when SMO is considered appropriate)

  • Acquired or congenital ankle deformity, including:
    • Post-osteomyelitis deformity (historically decades earlier)
    • Post-traumatic deformity leading to varus OA (including long-standing instability)
  • Asymmetric ankle OA
  • Joint space preservation criterion:
    • At least ~50% of the joint space remaining
  • Often after unsuccessful therapy of osteochondral lesions with deformity
  • Can be performed as preparation for later total ankle arthrodesis or arthroplasty

2) Contraindications / situations to avoid

  • Takakura stage 4 (not an indication)
  • Stage 3B treated as borderline / generally avoided for routine use
  • Infection:
    • Joint space infection / acute infection are contraindications
  • Poor bone/soft tissue quality or non-compliance
  • Relative contraindications discussed:
    • Older age (questioned usefulness in >70 years)
    • Smokers, especially combined with other risk factors
    • Non-reconstructible hindfoot instability
    • Significant pain at rest (suggests more advanced disease—possibly 3B/4)
    • Limited ankle mobility:
      • If ankle joint mobility is <30° (per cited Hintermann experience), expected improvement is limited

3) Preoperative assessment / imaging checklist

  • Radiographic views:
    • “Saltzman” ankle-centered views (with dorsal/plantar and sagittal context described)
    • Ankle AP mortise
    • Long-leg weight-bearing X-rays to identify proximal deformities requiring staged/combined correction
  • Advanced imaging (as needed):
    • MRI for cartilage/soft tissue assessment and planning combined techniques
    • SPECT-CT to identify osseous activity and painful joints not visible on X-ray
    • Weight-bearing CT (if available) or standard CT
  • Planning measurements (key angles mentioned):
    • Medial distal tibial articular angle (MDTAA) / medial distal tibial angle (target ~90–93°, ~±3.2°)
    • Talar tilt angle (normal discussed as <4°)
    • Tibiotalar surface angle
    • Tibial lateral surface angle
  • Measurement approach uses described geometric concepts (distance above joint line, circle/measurement concept).

4) Targets / “neutral alignment” principles

  • Correct MDTAA toward ~90–93°
  • Aim for overcorrection within a modest range:
    • Typical goal: ~2–4° overcorrection (varies slightly by subgroup)
  • Rationale:
    • Too little correction may leave residual eccentric overload
    • Too much correction may cause complications (e.g., translation effects, impingement, hinge-related issues)

5) Deformity magnitude → osteotomy type (technical decision logic)

Varus deformity (most common in their practice)

  • Medial opening wedge osteotomy
    • Used when varus deformity <10°
    • If MDTAA is approximately 82–92°
    • Aim 2–5° overcorrection, resulting in MDTAA about 94–97°
  • Lateral closing wedge osteotomy
    • Used when varus deformity >10°
    • Stated benefit: reduces risk of medial soft-tissue problems associated with large medial opening
  • Dome osteotomy
    • Consider if varus deformity >15°, especially to manage translation

Additional hindfoot/adjacent procedures (as needed)

  • Because SMO alone does not determine full alignment:
    • Calcaneal osteotomy
    • Subtalar fusion for severe instability/rotational problems (infra-malleolar stabilization)
    • Ligament reconstruction
    • Tendon transfers
    • Deltoid release / medial calcaneal procedures (in valgus/complex cases)
    • Peroneus longus-to-brevis transfers (mentioned as an option)
  • Emphasis: SMO should be part of a whole hindfoot/foot realignment plan, not just an ankle correction.

6) Surgical technique details highlighted (from practical cases)

Medial opening wedge technique elements

  • Osteotomy performed near the syndesmosis, with attention to that region:
    • More distal can be more stable, but distal placement increases syndesmosis injury risk
  • Use of hinge screw:
    • Used routinely to prevent lateral hinge cracking/instability
    • Claimed benefits:
      • more stable osteotomy
      • less postoperative swelling/pain in practice
      • fewer lateral hinge-related problems (per speaker experience)
  • Technique described (example workflow):
    • Plan correction size (example: mm correction)
    • Use K-wires/aiming wires
    • Slow controlled opening and controlled chiseling/spreader technique
    • Place bone graft in the gap
    • Fix with medial plate after hinge screw

Bone graft (opening wedge)

  • Bone graft used in all cases in the described practice
  • Example graft material mentioned: Tutoplast (femoral head-derived)

Fibula osteotomy considerations (tibia + fibula behavior)

  • Fibula osteotomy sometimes required depending on stability and deformity biomechanics
  • Evidence themes discussed:
    • Without fibula osteotomy, the fibula may hinder talus motion, leading to:
      • residual talar tilt
      • syndesmotic widening/impingement patterns
    • Radiographic improvement when fibula is addressed
  • Practice sequencing described:
    • Fix tibia first, then perform fibular osteotomy
    • Fibular osteotomy technique examples:
      • Weber B-like long cut (same side/position described)
      • In valgus arthritis: fibula may need distal shift and lengthening

7) Postoperative regimen (from Q&A)

  • Use a walker/splint:
    • 2 weeks: non-weight-bearing
    • After wound healing: partial weight-bearing (~15 kg) for 4 more weeks (in walker)
    • Gradual increase over the next 4–6 weeks
  • Total immobilization/boot duration:
    • ~10–12 weeks (range stated)

8) Cartilage management approach (from cases)

  • Cartilage repair may be done for localized cartilage lesions
  • Not necessarily applied to “classical arthritis” cases, but rationale is to support cartilage restoration before end-stage procedures.

Outcomes and comparative concepts emphasized

  • Survival/time horizon:
    • Average survival around ~88% at roughly 5 years (as described from literature discussion)
    • Longer follow-up examples exist (10–12+ years), but outcomes are variable.
  • Revision/next-step procedures:
    • In discussed literature cohorts: later TAR or arthrodesis occur in a minority, reflecting that SMO buys time.
  • Clinical vs radiological appearance:
    • Clinical improvement can occur even when radiographs look less ideal
    • Conversely, anatomical radiographic correction may not guarantee perfect clinical outcomes
  • Hindfoot/subtalar influence:
    • Failure to correct hindfoot rotational forces can lead to loss of ankle correction or persistent symptoms
    • Example: in peritalar instability with a zigzag deformity, subtalar fusion may be needed

Speakers / sources featured

Speakers (named)

  • Manish Bhatia — foot and ankle surgeon (Leicester); master of ceremonies/host introduction (also on behalf of BOFAS committees)
  • Professor Christina Stukenborg Kölsmann — Chief of Department of Foot and Ankle Surgery, Hannover Medical School; President of the German Foot and Ankle Society; BOFAS/EFAS committee roles (speaker on indications and planning)
  • Christian [surname unclear in subtitles] Class / Klas(s) — Senior surgeon, Hannover Medical School; chief editor, German Foot and Ankle Journal; European Foot and Ankle Society scientific committee; speaker on how to perform SMO

Referenced authors / study groups (as sources mentioned)

  • Takakura (2006): classification/staging (stage 1–4) and indications in stages 2–3A
  • Beat Hintermann (and group): clinical series and predictive value discussions
  • Nikola Krieger (2019): mid- and long-term results; large cohort
  • Knupp and Alexey Barg (mentioned among authors/literature sets)
  • Liang (2021): studies with/without fibula osteotomy and radiographic outcomes
  • Markus Knoop and Schulz Dürek(en) (2011): biomechanical/anatomical study on role of fibula stabilizing talus during correction
  • Haraguchi (JBJS 2015): correlation of weight-bearing Saltzman axis/clinical results; critique of 2D alignment measures
  • Paley (mentioned): principle relating osteotomy height to translation (higher correction height increases translation)
  • Alexey Barg (publication referenced in planning example)
  • Dwyer (calcaneal osteotomy mentioned as a technique)
  • Takakura MDTAA threshold and normal value range (as discussed in literature)

Original video