Hindfoot balancing in total ankle replacement: the role of supramalleolar osteotomies



To compare the obtained deformity correction and clinical/functional outcomes between patients who underwent total ankle replacement (TAR) with or without a concurrent supramalleolar osteotomy (SMO) to address a varus and/or recurvatum deformity of the distal tibia.


Data of 23 patients treated with an additional SMO to correct a varus and/or recurvatum deformity of the distal tibia at the time of TAR were prospectively collected. Twenty-three matched patients who underwent TAR only served as controls.


The American Orthopaedic Foot and Ankle Society (AOFAS)-hindfoot scale and pain assessed on a Visual Analogue Scale (VAS) did not significantly differ between the two groups at the final follow-up (AOFAS-hindfoot scale SMO/TAR group = 82 ± 10; TAR group = 82 ± 12; VAS pain SMO/TAR group = 1 (range, 0–4); TAR group = 1 (range, 0–5)). Ankle range of motion (ROM) did not improve in the SMO/TAR group (pre-operative = 27 ± 13 degrees, last follow-up = 30 ± 9 degrees; P = .294), but did improve in the TAR group (pre-operative = 31 ± 14 degrees, last follow-up = 39 ± 14 degrees; P = .049). Two patients who underwent SMO/TAR showed non-union of the tibial osteotomy, and two patients who underwent TAR only suffered from an intra-operative medial malleolar fracture.


An additional SMO during TAR in patients with a varus and/or recurvatum deformity of the distal tibia is not beneficial in most cases and should only be considered in pronounced multiplanar deformities.

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Correspondence to Nicola Krähenbühl.

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All royalties that the senior author (Beat Hintermann) received from Integra LifeSciences from 2005 to 2012 were given to the Orthopaedic Research Fund of the Kantonsspital Baselland. Dr. Barg reports personal fees from Medartis (outside the submitted work).

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Franz, AC., Krähenbühl, N., Ruiz, R. et al. Hindfoot balancing in total ankle replacement: the role of supramalleolar osteotomies. International Orthopaedics (SICOT) 44, 1859–1867 (2020). https://doi.org/10.1007/s00264-020-04681-z

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  • Total ankle replacement
  • Realignment surgery
  • Ankle osteoarthritis
  • Varus deformity