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Realignment Surgery for Valgus Ankle Osteoarthritis

Korrekturoperationen bei Valgusarthrose im oberen Sprunggelenk

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Operative Orthopädie und Traumatologie Aims and scope Submit manuscript

Abstract

Objective

Improvement of joint congruence, reduction of pain, slowdown of osteoarthritis progression, and prevention or delay of total ankle arthroplasty or ankle fusion.

Indications

Active patients with lateral valgus ankle joint degeneration.

Contraindications

Patients in poor general condition.

Inability to adhere to postoperative non-weight-bearing rehabilitation.

Distinct cartilage degeneration of more than half of tibiotalar joint surface.

Systemic joint disease.

Insufficiency of the deltoid ligament with tibiotalar subluxation malalignment.

Surgical Technique

Depending on stage of deformity:

Stage I – collapse of the lateral tibia plafond and/or lateral malleolar gutter with subsequent valgus ankle arthritis: medial closing-wedge osteotomy of the distal tibia. Derotation- lengthening osteotomy in case of fibula malunion.

Stage II – excessive calcaneus valgus: add medial sliding calcaneus osteotomy.

Stage III – forefoot-induced hindfoot valgus (flatfoot deformity with forefoot abduction): add repair/augmentation of the posterior tibial tendon, superficial delta and spring ligaments; gastrocnemius/triceps release; flexion osteotomy of the first cuneiform or metatarsal bone or fusion of the first tarsometatarsal joint.

Postoperative Management

Continuous active and passive range of motion starting at the 2nd postoperative day. Removable short leg cast during nights. Partial weight bearing for 6–8 weeks until osseous healing has occurred, followed by gradual return to full weight bearing and activity.

Results

14 patients with stage I, three with stage II, and five with stage III valgus ankle osteoarthritis were treated. In two cases realignment surgery failed and progressive painful arthritis was treated by arthroplasty. The other 20 patients improved at an average follow-up of 4.5 years (range 3–6.5 years). Eight patients (41%) were free of pain. Tibiotalar arthritis and alignment (Takakura Score) improved significantly and correlated with significant improvement of pain (visual analog scale) and function (American Orthopaedic Foot and Ankle Society Score).

Zusammenfassung

Operationsziel

Verbesserte Gelenkkongruenz, Schmerzreduktion, Aufhalten des Arthroseprozesses und zeitliches Hinausschieben von Arthroplastik oder Versteifung des oberen Sprunggelenks (OSG).

Indikationen

Aktive Patienten mit Valgusfehlstellung und lateraler Arthrose im OSG.

Kontraindikationen

Patienten in schlechtem Allgemeinzustand.

Unfähigkeit, das postoperative Rehabilitationsprogramm mit Entlastung durchzuführen.

Fortgeschrittene Arthrose mit Degeneration von mehr als der Hälfte der tibiotalaren Gelenkfläche.

Systemische Gelenkerkrankung

Insuffizienz des gesamten Ligamentum deltoideum mit tibiotalarer Subluxation.

Operationstechnik

In Abhängigkeit vom Stadium der Deformität:

Stadium I – Kollaps des lateralen Pilon tibiale und/oder des fibulotalaren Malleolargelenks mit konsekutiver Valgusarthrose: Medial zuklappende Osteotomie der distalen Tibia. Fibulaosteotomie zur Derotation und Verlängerung bei Pseudarthrose.

Stadium II – Valgusfehlstellung der Ferse: Zusätzliche Durchführung einer medialen Verschiebeosteotomie des Tuber calcanei.

Stadium III – Valgusfehlstellung der Ferse, induziert durch eine Vorfußabduktion bei Pes planovalgus: Zusätzliche Durchführung einer Naht/Augmentation der Tibialis-posterior-Sehne, des vorderen Ligamentum deltoideum und des Ligamentum calcaneonavicular, einer Verlängerung des Musculus gastrocnemius/Musculus triceps, einer Flexionsosteotomie des Os cuneiforme mediale/Metatarsale I oder einer Versteifung des ersten tarsometatarsalen Gelenks.

Weiterbehandlung

Aktive und passive Bewegungsübungen im OSG ab dem 2. postoperativen Tag. Entfernbarer Unterschenkelgipsverband. Sohlenkontakt für 6–8 Wochen postoperativ bis zur Knochenheilung. Anschließend schrittweiser Übergang zur Vollbelastung.

Ergebnisse

14 Patienten im Stadium I, drei im Stadium II und fünf im Stadium III wurden Korrekturoperationen bei Valgusarthrose im OSG unterzogen. In zwei Fällen kam es zur Ausbildung einer progressiven schmerzhaften OSG-Arthrose, welche mittels OSG-Prothese therapiert wurde. Die übrigen 20 Patienten zeigten nach einer mittleren Nachkontrollzeit von 4,5 Jahren (3–6,5 Jahre) eine Verbesserung der Studienvariablen. Acht Patienten (41%) waren schmerzfrei. Tibiotalare Arthrose und Alignment (Takakura-Score) verbesserten sich signifikant und korrelierten mit der Verbesserung der Schmerzen (visuelle Analogskala) und der Funktion (Score der American Orthopaedic Foot and Ankle Society).

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Authors and Affiliations

  1. Department of Orthopedics and Traumatology, University Hospital, Bonn, Germany

    Beat Hintermann

  2. Oberarzt Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Germany

    Geert Pagenstert

Authors
  1. Geert Pagenstert
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  2. Markus Knupp
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  3. Victor Valderrabano
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  4. Beat Hintermann
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Corresponding author

Correspondence to Geert Pagenstert.

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Pagenstert, G., Knupp, M., Valderrabano, V. et al. Realignment Surgery for Valgus Ankle Osteoarthritis. Orthop Traumatol 21, 77–87 (2009). https://doi.org/10.1007/s00064-009-1607-9

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  • DOI: https://doi.org/10.1007/s00064-009-1607-9

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