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. 2024 Mar 26;14(4):747–754. doi: 10.1007/s13534-024-00370-7

The effects of medial soft tissue release for varus deformity during medial open wedge supramalleolar osteotomy: a cadaveric study

Dai-Soon Kwak 1,#, Inha Woo 2,#, Jung-Min Lee 3, Eunah Hong 4, Chul Hyun Park 5,✉,#
PMCID: PMC11208347  PMID: 38946821

Abstract

This study was performed to investigate the effects of fibular osteotomy and release of medial soft tissues including posterior tibial tendon (PTT), and deep deltoid ligaments, which act as medial stabilizing structures in medial open wedge SMO. Twelve fresh frozen human legs were obtained and disarticulated below the knee. Experiments were conducted in four steps. First, medial open wedge tibial osteotomy was performed. Second, fibular osteotomy was performed in an inferomedial direction at the same level as the tibial osteotomy. Third, the deep deltoid ligament was released from tibial attachments. Forth, total tenotomy of the PTT was performed behind the medial malleolus. After finishing each step, contact area and peak and mean pressures were measured in the tibiotalar and talofibular joints. Fibular osteotomy after medial open wedge SMO significantly decreased mean pressure in the tibiotalar joint, mean and peak pressures in the talofibular joint. Medial soft tissue release resulted in a remarkable lateral shift and decreased tibiotalar joint loading. However, no remarkable change was observed in the tibiotalar joint during releasing medial soft tissues. The overall peak pressure distribution tended to shift more laterally compared to the value of normal alignment. In conclusion, concomitant fibular osteotomy and release of the deltoid ligament and PTT provide a useful means of minimizing tibiotalar joint stress.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13534-024-00370-7.

Keywords: Ankle, Osteoarthritis, Supramalleolar osteotomy, Fibular osteotomy

Introduction

Supramalleolar osteotomy (SMO) is a representative joint-preserving procedure for varus ankle osteoarthritis (OA) as it corrects the weight-bearing axis and load transfer across the ankle joint [1, 2]. Many authors have advocated the use of SMO since Takakura et al. reported medial open wedge SMO results for correcting post-traumatic varus distal tibial deformities [2, 3]. In most patients with varus distal tibial deformity, especially an asymmetric varus ankle OA in which the talus is tilted into varus within the ankle mortise, medial open wedge osteotomy is usually sufficient for correction [4].

After correcting the distal tibial deformity after SMO, various procedures can be implemented. When selecting additional procedures, certain options remain controversial. The most contentious among them is whether concomitant fibular osteotomy should be performed, with no clear indications so far. [5–10] There are still many advantages and disadvantages following it. [6] It can shift the mechanical axis further laterally and reduce the risk of pain development due to subfibular impingement [6]. Some have suggested that radiologic values such as talar tilt and medial displacement significantly improved after combined fibular osteotomy [8, 10]. On the other hand, Ahn et al. reported significant improvements in clinical outcomes in a cohort study of patients who received SMO without fibular osteotomy [5].

Correct soft tissue balance keeps joints aligned during motion [11–13]. In the case of the ankle joint, the deltoid ligament complex and the posterior tibial tendon (PTT) are the most important dynamic medial stabilizers [14–16]. Due to the presence of substantial medial soft tissue contracture in cases of severe varus deformity of the ankle joint, adequate medial soft tissue balance is crucial to obtain the proper correction [17]. On the other hand, insufficiency of medial soft tissue structures caused by excessive release may break down the medial longitudinal arch [18]. However, to the best knowledge, no biomechanical studies have addressed medial soft tissue balancing with SMO, and surgical indications are limited.

This study aimed to examine the effect of combined fibular osteotomy and medial soft tissue release on the tibiotalar and talofibular joints using cadaveric medial open wedge SMO models [19, 20]. We hypothesized that SMO with combined fibular osteotomy and medial soft tissue release would reduce tibiotalar joint stress and increase talofibular joint stress.

Materials and methods

Specimen preparations

Twelve fresh-frozen human legs (five male and one female donor) with mean age of 73.6 years (50–84) were included in the present study. All specimens were thawed for at least 24 h at room temperature. After thawing, the motion of the ankle joint was checked, and cadavers with severe joint contracture were excluded. In addition, cadavers with severe advanced arthritis or hindfoot malalignment were excluded based on radiographs. Disarticulation was performed at the knee joint and the medullary canal was drilled. Skin and subcutaneous tissues were dissected around the ankle, and interosseous membranes, ligaments, and tendons were preserved to retain as much soft tissue as possible. Axial loading was applied using a customized load transmitter with a stem in the tibial medullary canal. Each leg was held upright inside a load frame within a universal testing machine (Instron, Model 5567, Norwood, MA, USA) to simulate a single-leg, barefoot stance. A custom-made calibration jig was attached to the Instron actuator, and the forefoot was strapped for stabilization (Fig. 1).

Fig. 1.

Fig. 1

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Biomechanical test of the lower leg. (a) A disarticulated lower leg was held in an upright position. The leg was free-standing, stabilized by a forefoot strap, and secured by the pressure exerted by the axial load. (b) TekScan sensors were inserted into tibiotalar and talofibular joints. (c) Sensor edges were connected by Vicryl 2 − 0 sutures to two screws inserted into the non-articular area of the calcaneum to prevent sensor damage

Contact area, mean pressure, and peak pressure were evaluated in the tibiotalar and talofibular joints using the K-scan 6900 pressure mapping sensor system (Tekscan, South Boston, MA, USA). All measurements were previously calibrated according to the manufacturer’s guidelines. A sensor array was used to receive and transmit information to the pressure mapping system. Two of four independent sensor arrays were used with a matrix area of 196 mm2 (14 mm x 14 mm), 121 sensors (11 × 11), and a density of 62.0 sensors/cm2 (a sensor is a basic element of a sensor array). Arthrotomies of the anterior, posterior, and lateral ankle joints were performed to insert sensors into the tibiotalar and talofibular joints. Because each talar dome size varied among the specimens, it was determined that the sensor should be placed along the medial border of the talar dome to focus on changes on the medial side. Another sensor was placed in the talofibular joint. Care was taken to maximize its surface area to cover the entire articular surface. The sensor edges were threaded to two screws inserted in the non-articular area of the calcaneum to prevent damage of the sensor (Fig. 1).

Biomechanical testing

Fifteen preconditioning cycles were performed with a 700 N load, and then the static axial compression from the upright loading machine was continuously increased from a 50 N preload to 700 N, representing a single-leg stance for average body weight [7]. Maximum load was maintained for 2 s, and contact area, peak and mean pressures were recorded for analysis. Peak pressures were recorded at 50 Hz, and the peak pressure distribution was recorded until the load was released [9, 21].

Surgical procedures

Intact values of peak and mean pressure and surface area were recorded after dissection before surgical procedures. All surgical procedures, which consisted of four steps, were performed by a senior orthopaedic surgeon (C.H.P.).

First, a medial open wedge tibial osteotomy was performed for proximal syndesmosis. After minimal stripping of the periosteum, an oscillating saw was used to preserve the lateral cortex of the distal tibia, [22] and the osteotomy was initiated 4 to 5 cm proximal to the medial malleolar tip [23]. Multiple holes using Kirschner wire were made in the lateral cortex of the osteotomy site to preserve the lateral cortex, and the osteotomy was completed by inserting a thin osteotome. A lamina spreader was then used to widen the gap until a sufficient gap was achieved. The osteotomy site was then fixed with a tibial anatomical locking plate (Ohtofix, Ohtomedical Co. Ltd., Goyang, Korea) using a 9 mm metal block. A 9 mm metal block, one of the most commonly used sizes in the clinical scenario, was specified to standardize the gap height between specimens. An identical osteotomy gap (9 mm) was decided to be used as a control to standardize the difference according to the gap [24]. Second, a fibular osteotomy at the same level as the tibial osteotomy inferomedially, [25] and the fibular osteotomy site was fixed with a fibular anatomical locking plate (Ohtofix, Ohtomedical Co. Ltd., Goyang, Korea). Third, the deep deltoid ligament was released at the tibial attachment, taking care not to injure the superficial deltoid ligament [26]. Finally, a total tenotomy of the PTT was performed behind the medial malleolus, taking care not to injure other structures (Fig. 2). After each step, all parameters were evaluated using the K-scan.

Fig. 2.

Fig. 2

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The posterior tibial tendon was released posterior to the medial malleolus. Care was taken to avoid damaging other anatomical structures

Statistical analysis

A priori power analysis based on the results of a previous biomechanical study suggested that 11 specimens would provide statistically meaningful results in MPa for a standard deviation of 0.8 and a P-value of < 0.05 [22]. The analysis was performed using SPSS for Windows, Ver. 16.0.0 (SPSS Inc., Chicago, IL, USA). Due to the small sample size, continuous variables were assessed for normality using the Shapiro-Wilk test [27]. Means and standard deviations were also calculated. The t-test was used when variables appeared to be normally distributed, and the Mann-Whitney U test was used when distributions were not normal. Statistical significance was accepted for P values < 0.05.

Results

All specimens in this study had a hindfoot angle within neutral to valgus 5°. Contact area, peak and mean pressures in the tibiotalar joint are shown in Fig. 3; Table 1. A linear mixed model was used to determine the effect of each surgical procedure using the K-scan. Tibial osteotomy increased contact area and mean pressure but decreased peak pressure compared to intact values (p < 0.05). Fibular osteotomy then significantly decreased mean pressure in the talar dome (p = 0.019). Deltoid ligament and PTT tenotomy then decreased contact area and peak pressure, respectively (p = 0.027, p = 0.033).

Fig. 3.

Fig. 3

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Changes in (a) contact area, (b) peak and (c) mean pressures in the tibiotalar joint during the surgical procedures. Values were compared with their values after the previous surgical step. Asterisks indicated P-values of < 0.05

Table 1.

Biomechanical outcomes of different conditions (means ± standard deviations). P-values are for comparisons versus intact values

Parameters Tibiotalar joint Talofibular joint
Estimation (mean ± SD) p-value Estimation (mean ± SD) p-value
Contact Area (mm2) Intact 137.9 ± 20.3 36.3 ± 5.1
Tibia 146.3 ± 5.9 < 0.01 65.3 ± 10.8 < 0.01
Fibula 162.1 ± 7.1 < 0.01 66.6 ± 9.9 0.026
Deltoid 144.8 ± 6.0 0.131 56.5 ± 10.6 0.041
PTT 135.6 ± 9.8 0.933 51.6 ± 9.4 0.059
Peak Pressure (KPa) Intact 6845 ± 495 266.5 ± 77.2
Tibia 5782 ± 605 0.021 1514.1 ± 541.1 < 0.01
Fibula 5429 ± 570 0.073 2615.5 ± 298.9 < 0.01
Deltoid 5066 ± 705 0.026 2178.1 ± 312.5 < 0.01
PTT 4310 ± 707 < 0.01 2145.0 ± 339.3 < 0.01
Mean Pressure (KPa) Intact 1529 ± 110 18.3 ± 8.2
Tibia 1587 ± 132 0.409 328.9 ± 95.3 < 0.01
Fibula 1497 ± 186 0.911 238.3 ± 45.7 < 0.01
Deltoid 1340 ± 210 0.134 219.7 ± 47.8 < 0.01
PTT 873 ± 214 0.013 190.1 ± 47.0 < 0.01
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PTT, posterior tibial tendon

Changes in measured values in the talofibular joint are shown in Fig. 4; Table 1. Values were compared with those after previous steps. Contact area, peak and mean pressures increased significantly after tibial osteotomy (p < 0.01) and then decreased. In particular, deltoid ligament release significantly decreased peak pressure (p = 0.027), and PTT tenotomy caused non-significant changes in the three parameters (p > 0.05).

Fig. 4.

Fig. 4

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Changes in (a) contact area, (b) peak and (c) mean pressures in talofibular joints after surgical procedures (in order). Values were compared with values after the previous step. Asterisks indicated P-values of < 0.05

Peak pressure distributions on the talar dome after each surgical step are shown as a color plot in Fig. 5. The size of the talar dome varied amongst the specimens. Therefore, only approximate positions are shown in this figure. Each sensor array consisted of 121 sensors. (11 × 11) In most limbs, peak pressures were initially located central to the medial side of the talar dome. Subsequent surgical steps tended to shift the peak pressures laterally.

Fig. 5.

Fig. 5

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Tibiotalar joint peak pressure distributions on the talar dome. Warmer colors indicate higher pressures. Each number represents the relative location of the peak pressure of the specimen (1–12). (a) Intact, (b) after tibial osteotomy, (c) after fibular osteotomy, (d) after deltoid ligament release, and (e) after posterior tibial tendon release *The size of the talar dome between specimens were different. Therefore, exact position is different and only approximate positions were presented in this figure

Discussion

Fibular osteotomy after medial open wedge SMO resulted in a significant decrease in mean pressure in the tibiotalar joint, as well as mean and peak pressures in the talofibular joint. These findings are similar to those reported in several previous cadaveric studies [10]. Releasing the medial soft tissue showed a remarkable lateral shift and decrease in tibiotalar joint loading. The strength of the present study lies in its ability to examine the biomechanical effects of a combination of fibular osteotomy and medial soft tissue release on both the tibiotalar and talofibular joints.

Choi et al. stated that medial open wedge SMO combined with fibular osteotomy can cause more lateral translation of the talus than medial open wedge SMO without fibular osteotomy [6]. They also reported that combined fibular osteotomy decreased the talofibular joint pressure increase observed after tibial osteotomy, but did not affect the tibiotalar joint pressure. Our results are consistent with these findings, as significnat decreases in peak and mean pressures in the talofibular joint and a lateral talar shift of the talar dome were observed after fibular osteotomy. Recently, Lim et al. [13] reported that lateral shift of the talus and widening of the medial gap were achieved after combined fibular osteotomy. The present study also showed a remarkable decrease in the mean pressures at the tibiotalar joint, which was a unique finding of this study. The valgization effect after fibular osteotomy is thought to have caused the marked reduction in mean pressure. There is currently no accepted definitive indication for fibular osteotomy during SMO. However, our study suggests that fibular osteotomy may be necessary during medial open wedge SMO to reduce talofibular joint loading.

The deltoid ligament, also known as the medial collateral ligament complex of the ankle joint, is a strong, broad ligament that originates at the medial malleolus and inserts into the talus, calcaneus, and navicular bone, and separates into a superficial and a deep layer. [28] In addition, the deltoid ligament maintains medial ankle stability, and the superficial portion of the medial ankle plays an important role in maintaining rotational ankle stability. Rasmussen et al. [29, 30] reported various functions of the deltoid ligament and investigated the limitation of talar abduction by the superficial layers. Hintermaan et al. [28] found that loss of the tibionavicular and spring ligaments results in increased internal rotation of the lower leg, leading to symptomatic instability or laxity of the anterior talofibular ligament. Whereas loss of the deep portion of the deltoid ligament, including the anterior tibiotalar and posterior tibiotalar ligaments, can shift its mechanical axis laterally and correct varus deformity of tibial plafond [31]. Recently, an important radiographic indicator after SMO has been the migration of the talus center [5]. Although still scientifically unproven, its clinical importance is growing [32]. It is believed that contracture of the medial soft tissues exacerbated the medial displacement of the talus. Therefore, releasing the medial soft tissues can correct the medial migration of the talus center. The need to release the deltoid ligament has been suggested in several studies, [22, 33] but there have been few literatures with concrete biomechanical outcomes. The substantial decrease of contact area in the tibiotalar joint was observed in this study, which is another unique strength of our study.

In patients with varus ankle osteoarthritis, remaining inframalleolar deformity may be the result of medial soft tissue contractures. PTT overactivity may contribute to spastic ankle varus deformity [34]. Hintermann et al. [17] recommended releasing the PTT in patients with severe ankle varus osteoarthritis with contractures. However, little information is available on how to obtain appropriate medial soft tissue balance during medial open wedge SMO. The PTT is primarily responsible for plantar flexion and inversion of the foot and is highly associated with flatfoot deformity. Therefore we decided that PTT tenotomy would be the final step required to correct varus deformity [35, 36]. Park et al. stated that PTT transfer, often combined with bony alignment procedures, provides a reasonable option for painful varus ankle arthritis with hindfoot varus [22]. Transferring the PTT could convert the deforming force to a reducing force in varus ankle arthritis. Based on our results, although we decided to perform PTT tenotomy as the final step rather than PTT transfer, PTT tenotomy caused a significant decrease in mean and peak pressures in the tibiotalar joint. Therefore, surgeons should consider that concomitant PTT and deltoid ligament release can lead to unpredictable gap increments and over-release problems. We recommend that intraoperative confirmation of adequate soft tissue balance is necessary.

Our study had some limitations. First, we aimed to investigate the effects of concomitant fibular osteotomy and medial soft tissue release. However, SMO not only corrects coronal deformity but also influences deformity in the sagittal plane, subtalar motion, and hindfoot alignment, and these variables were not taken into account due to the complexity involved. Moreover, SMO is expected to correct the distal deformity of the lower leg. The whole length of lower limb had not been considered in this study. Therefore, we suggest additional research be performed using the other technique, such as finite element analysis, to simulate mechanisms of the whole lower limb. Second, most of the specimens in the present study did not have medial ankle osteoarthritis or varus deformity. While the outcomes may have varied in limbs with genuine ankle arthritis, we contend that our findings offer valuable insights into the manner in which our specified techniques can indeed influence ankle dynamics in cadaveric models. Nonetheless, careful interpretation is required. Finally, all specimens underwent identical sequential surgical steps in the order; tibial osteotomy, fibular osteotomy, deltoid ligament release, and PTT tenotomy. However, there is no established orders of previous other studies in SMO. Because bony procedures could easily correct the overall deformity, the fibular osteotomy was preceded by other medial soft tissue procedures. In addition, the medial stabilizing force was found to decrease rapidly after PTT release. Therefore, we consider that depending on the surgeon’s preference, releasing either of PTT or the deltoid ligament can result in soft tissue balancing.

Conclusion

Fibular osteotomy after medial open wedge SMO significantly decreased the mean and peak pressure loadings of the talofibular joint. Medial soft tissue release resulted in a remarkable lateral shift and decrease in tibiotalar joint loading. Furthermore, our findings indicate adequate release of the deltoid ligament and PTT might minimize tibiotalar joint stress and caution that surgeons should consider the effects of fibular osteotomy and medial soft tissue release in open wedge SMO.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1 (21KB, docx)
Supplementary Material 2 (361.3KB, pdf)
Supplementary Material 3 (4.2MB, pdf)

Acknowledgements

Not applicable.

Abbreviations

SMO

Supramalleolar osteotomy

PTT

Posterior tibial tendon

OA

Osteoarthritis

Author contributions

Dai-Soon Kwak and Inha Woo contributed equally to this study as co-first authors. Inha Woo and Chul Hyun Park Woo conceived and designed the experiments. Jung-Min Lee, Dai-Soon Kwak, and Chul Hyun Park performed the searches and experiments. Inha Woo and Jung-Min Lee analyzed and interpreted data. Inha Woo and Dai-Soon Kwak wrote the manuscript. Chul Hyun Park reviewed the manuscript. All authors read and approved the final manuscript.

Funding

This research was supported by a grant from the MD-PhD/Medical Scientist Training Program through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea.

Data availability

The datasets used and/or analyzed are available from the corresponding author on receipt of reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved beforehand by the Institutional review board of Catholic University Hospital. (reference No. MC21EIDI0149). All cadavers were supplied by the department of Anatomy, Catholic University, Seoul, Republic of Korea. Patient consent was waived for this cadaveric study. Therefore, it was not possible to identify participants.

Consent for publication

This manuscript does not contain any individualized information.

Competing interests

The authors have no competing interests to declare.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Dai-Soon Kwak and Inha Woo contributed equally to this study (Co-1st authors).

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Material 1 (21KB, docx)
Supplementary Material 2 (361.3KB, pdf)
Supplementary Material 3 (4.2MB, pdf)

Data Availability Statement

The datasets used and/or analyzed are available from the corresponding author on receipt of reasonable request.

Articles from Biomedical Engineering Letters are provided here courtesy of Springer

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