Abstract
Aims
Varus ankle arthritis with excessive talar tilt (TT) angle often has unsatisfactory outcomes after supramalleolar osteotomy (SMOT) surgery. These patients have a 3D deformity involving the hind foot as well as the ankle. Thus, adjuvant correction of the hind foot component may contribute to the TT angle. This study aimed to explore whether calcaneal osteotomy combined with SMOT could effectively correct the hindfoot alignment to treat varus ankle arthritis with a large TT angle.
Methods
In total, 26 patients diagnosed with varus ankle arthritis with excessive TT angle were included in this study. Calcaneal osteotomy was combined with SMOT to correct the hindfoot alignment. Thus, a combination of supramalleolar and subtalar corrections was performed to improve the alignment of the lower limbs. Anterior and lateral radiographs of the weightbearing ankle were performed preoperatively and postoperatively. The tibial anterior surface angle, the tibial lateral surface angle, and TT angle were measured. The clinical efficacy was evaluated according to the American Orthopaedic Foot and Ankle Society scoring system and pain visual analogue scale.
Results
Preoperative varus hindfoot alignment was corrected to nearly normal via SMOT combined with calcaneal osteotomy. Radiological parameters demonstrated that SMOT combined with calcaneal osteotomy could significantly improve varus ankle arthritis and correct excessive TT angle. Moreover, the clinical outcomes of the patients were significantly improved and the pain was significantly relieved after the surgery.
Conclusion
We found that SMOT combined with calcaneal osteotomy significantly improved varus ankle arthritis with a significant reduction in TT angle. Therefore, with the correction of the subtalar alignment and the displacement of the talus centre, the hindfoot alignment can recovery effectively and the TT angle can be significantly reduced. This suggests that SMOT combined with calcaneal osteotomy is a practical surgical approach for varus ankle arthritis with excessive TT angle.
Cite this article: Bone Jt Open 2025;6(11):1343–1348.
Keywords: Varus ankle arthritis, Supramalleolar osteotomy, Calcaneal osteotomy, Talar tilt angle, ankle arthritis, hindfoot alignment, ankles, American Orthopaedic Foot and Ankle Society scoring, clinical outcomes, surgical approach, lower limbs, talus
Introduction
Ankle osteoarthritis is a degenerative disease affecting up to 1% of adults. It involves extensive articular cartilage damage caused by multiple factors, with trauma accounting for approximately 80% of cases.1,2 Recurrent sprains and ankle fractures are primary causes of secondary traumatic ankle arthritis.3 Patients with ankle arthritis often present with limb malalignment (valgus or varus), with varus deformity being more common.4 In varus ankle arthritis, pathology primarily affects the medial compartment of the distal tibial articular surface.1
Supramalleolar osteotomy (SMOT) was first proposed by American scholars Speed and Boyd5 in 1936. In 1995, Takakura et al6 first systematically reported the clinical efficacy of SMOT, and subsequently SMOT became widely used in the treatment for early-to-mid-stage asymmetric ankle osteoarthritis.7 Recently, accumulating studies have found that timed SMOT in early varus ankle arthritis can reduce joint destruction and contact pressure during tibiotalar joint movement, thereby avoiding or delaying the need for arthrodesis or joint arthroplasty.2,8 Previous studies suggested that SMOT is mainly suitable for young patients with Takakura stage II9 and IIIa. Recent evidence supports its use in patients with stage IIIb, and favourable clinical outcomes have been obtained.8 However, varus ankle arthritis combined with excessive talar tilt (TT) angle, frequently observed in patients with Takakura stage IIIb, poses a challenge as postoperative TT angle maintenance remains difficult.10,11 This compromises surgical outcomes and patient satisfaction, an issue yet to be resolved.
Varus ankle arthritis with excessive TT angle represents a 3D, multiplanar degenerative deformity that often involves an increased TT angle.4 Moreover, when the preoperative TT angle is > 7.3°, a high TT angle tends to occur after SMOT surgery, leading to suboptimal surgical outcomes.10-12 In these patients, talar internal rotation is often accompanied by inward shift of the rotation centre and calcaneus varus. Thus the lower limb alignment is combined with the abnormality of the submalleolar alignment in addition to the supramalleolar abnormality. In this study, we pioneered a combined SMOT and calcaneal osteotomy procedure to correct the hindfoot alignment in varus ankle arthritis with excessive TT angle. Concurrent medial deltoid ligament release and lateral collateral ligament tightening were also performed. The combination of supramalleolar and submalleolus levels correcting the alignment of the lower limbs aims to establish the optimal surgical strategy for varus ankle arthritis with excessive TT angle.
Methods
Patients
A total of 26 ankles (26 patients) who underwent SMOT combined with calcaneal osteotomy were analyzed retrospectively in our department from 2018 to 2022. The Takakura classification system11 was used to assess the osteoarthritis stage and there were zero cases of stage I, five stage II, seven stage IIIa, 14 stage IIIb, and zero of stage IV. Among them, there were 11 males and 15 females, aged from 45.1 to 62.7 years, with an average age of 52.4 years (SD 3.6). All patients were followed up for at least 24 months with a median duration of 2.5 years. This study was performed in accordance with the Declaration of Helsinki,13 and approved by the Institutional Research Committee of the Honghui Hospital, China, where the corresponding author (XW) works (protocol number 20240127). All the patients signed informed consent forms.
Inclusion and exclusion criteria
The inclusion criteria was: 1) confirmed varus ankle arthritis with excessive TT angle (TT > 7.3°)10-12 by radiograph, with surgical indications and no contraindications to surgery; 2) with obvious pain and functional impairment, and no significant improvement in symptoms after conservative treatment; and 3) follow-up for at least two years and complete data. The exclusion criteria was: 1) those combined with bone tumours or rheumatoid arthritis; 2) with primary nerve or muscle disease of the lower limbs; and 3) with other foot and ankle deformities.
Operative technique
In order to perform SMOT, the patient is placed under general anesthesia, and an incision of 6 cm to 8 cm is made on the anteromedial aspect of the ankle to fully expose the anteromedial space of the ankle. The osteotomy line is located 4 cm to 5 cm above the tip of the medial malleolus and is first positioned with a K-wire. Subsequently, the oblique line of osteotomy is amputated from the medial to the lateral, and the lateral cortex is preserved. Then, the osteotomy gap is opened, the osteotomy gap is filled with autologous bone, and internal fixation is carried out after the orthopaedic effect is satisfactory after fluoroscopy confirmation (Figure 1).
Fig. 1.
Operative techniques used in the current study. a) Supramalleolar osteotomy; and b) calcaneal osteotomy.
Then the medial deltoid ligament of the ankle joint is released. At the same horizontal plane of the osteotomy above the lateral ankle, the fibula is fully exposed by incision about 5 cm with C-arm positioning. After a Z-shaped osteotomy, a small wedge of bone is removed on both sides. The ankle joint is completely everted, and the osteotomy line is fixed with a screw. The lateral collateral ligament of the ankle joint is then tightened. This is followed by an osteotomy of the calcaneus. At 1 cm on the posterior border of the short and long peroneal tendon, an oblique osteotomy is made on the lateral side of the calcaneus from lateral to medial. The osteotomy line is at a 45° angle to the plantar and perpendicular to the calcaneus. The osteotomy line completely penetrates the medial cortex moving the posterior tuberosity mass of the calcaneus laterally (Figure 1).
The postoperative management for the surgery comprises four key phases: 1) initial wound dressing changes are performed at three to five days postoperatively; 2) sutures are removed at the two-week mark; 3) cast immobilization is maintained for four weeks, after which non-weightbearing range-of-motion exercises are initiated; and 4) radiological evaluation is conducted at two to three months post-surgery to determine progressive weightbearing status based on confirmed bone healing.
Clinical and radiological evaluation
Clinical evaluation was performed preoperatively and at the last follow-up. The American Orthopaedic Foot and Ankle Society (AOFAS) score14 was used for the evaluation of clinical outcomes including pain (40 points), function (50 points), and alignment (10 points). The degree of pain was quantified using a visual analogue scale (VAS) from 0 to 10, with 0 being no pain and 10 being the worst pain. VAS evaluation can directly reflect the patient’s pain relief before and after surgery,15 while AOFAS is an authoritative international evaluation system that reflects the improvement of the foot comprehensively.14
Anterolateral ankle radiographs in a weightbearing position were taken preoperatively and at last follow-up. Radiological indicators – tibial anterior surface (TAS) angle, tibial lateral surface (TLS) angle, TT angle, and talar centre migration (TCM) – were measured. For the evaluation of hindfoot alignment, the hindfoot alignment angle (HAA) and hindfoot moment arm (HMA) were also measured, as previously described.16,17 All measurements were performed on radiographs by personnel who were not involved in the surgery but were trained in specialties to avoid the presence of bias.
Statistical analysis
The data were processed using SPSS 24.0 statistical software (IBM, USA), and the normally distributed metrics were expressed as mean (SD). The paired t-test was used to compare the preoperative and postoperative radiological parameters, AOFAS score, and VAS scores. A value of p < 0.05 was considered statistically significant.
Results
Correction effect of SMOT combined with calcaneal osteotomy
A total of 26 ankles (26 patients) that underwent SMOT combined with calcaneal osteotomy were involved in the current study. All patients were followed up for at least 24 months with a median duration of 2.5 years. Anteroposterior and lateral ankle radiographs in a weightbearing position were taken preoperatively (Figure 2) and at last follow-up (Figure 2). The radiological images demonstrated that preoperative varus hindfoot alignment was corrected to nearly normal via SMOT combined with calcaneal osteotomy.
Fig. 2.
Radiological images taken: a) preoperatively; and b) and at last follow-up. Varus hindfoot alignment was observed preoperatively, and hindfoot alignment angle was corrected to nearly normal after supramalleolar osteotomy combined with calcaneal osteotomy.
Two cases developed postoperative complications. One presented with surgical site infection that resolved with local wound care. The other demonstrated restricted ankle range of motion which showed significant improvement following intensive rehabilitation. These results suggest that combination of supramalleolar and submalleolus correction was a practical surgical option for varus ankle arthritis with excessive TT angle.
Pre- and postoperative radiological scores
The radiological scores demonstrated that TAS angle improved from 81.7° (SD 3.7°) to 91.8° (SD 3.7°), and TLS angle increased from 79.4° (SD 4.0°) to 83.3° (SD 2.6°) (Table I). Both TT angle (11.2° (SD 3.9°) vs 2.9° (SD 1.4°)) and TCM (4.9 mm (SD 1.9) vs 1.7 mm (SD 1.0)) were significantly decreased. In addition, HAA (16.4° (SD 5.2°) vs 3.5° (SD 1.9°)) and HMA were significantly decreased after surgery (24.7 mm (SD 5.8) vs 3.3 mm (SD 2.0)). Theses radiological parameters confirmed that SMOT combined with calcaneal osteotomy could significantly improve varus ankle arthritis and correct excessive TT angle.
Table I.
Preoperative and postoperative final follow-up results of radiography.
| Variable | Preoperative, mean (SD) | Final postoperative follow-up, mean (SD) | p-value* |
|---|---|---|---|
| TAS angle, ° | 81.7 (3.7) | 91.8 (3.7) | < 0.001 |
| TLS angle, ° | 79.4 (4.0) | 83.3 (2.6) | < 0.001 |
| TT angle, ° | 11.2 (3.9) | 2.9 (1.4) | < 0.001 |
| TCM, mm | 4.9 (1.9) | 1.7 (1.0) | < 0.001 |
| HAA, ° | 16.4 (5.2) | 3.5 (1.9) | < 0.001 |
| HMA, mm | 24.7 (5.8) | 3.3 (2.0) | < 0.001 |
Paired t-test.
HAA, hindfoot alignment angle; HMA, hindfoot moment arm; TAS, tibial anterior surface; TCM, talar centre migration; TLS, tibial lateral surface; TT, talar tiltangle.
Pre- and postoperative results of AOFAS score and VAS
The clinical outcomes of the patients were significantly improved and the pain was significantly relieved after the surgery. These results indicated that AOFAS score was significantly improved from 53.3 (SD 6.5) preoperatively to 85.3 (SD 7.2) postoperatively at final follow-up (Table II). Moreover, VAS was significantly decreased from 5.4 (SD 1.3) preoperatively to 1.1 (SD 0.3) postoperatively at final follow-up (Table II).
Table II.
Preoperative and postoperative final follow-up results of American Orthopaedic Foot and Ankle Society score and visual analogue scale.
| Variable | Preoperative, mean (SD) | Final postoperative follow-up, mean (SD) | p-value* |
|---|---|---|---|
| AOFAS | 53.3 (6.5) | 85.3 (7.2) | < 0.001 |
| VAS | 5.4 (1.3) | 1.1 (0.3) | < 0.001 |
Paired t-test.
AOFAS, American Orthopaedic Foot and Ankle Society; VAS, visual analogue scale.
Discussion
Varus ankle arthritis with increased TT angle represents a 3D multiplanar degenerative deformity with high postoperative recurrence rates.1 Internal rotation of the talus typically coincides with an inward shift of rotation centre and calcaneus varus.18,19 Therefore, in addition to the supramalleolar abnormality, the lower limb alignment is also combined with abnormality of the submalleolar alignment. In the current study, we introduced a novel surgical approach combining supramalleolar osteotomy and submalleolar osteotomy. Following the supramalleolus open wedge osteotomy to correct supramalleolar deformity, the calcaneal osteotomy addressed hindfoot malalignment. This dual-level strategy effectively managed varus ankle arthritis with excessive TT angle by comprehensively realigning the lower limb through coordinated supramalleolar and inframalleolar corrections.
Clinically, we have found that the TT angle of varus ankle arthritis is difficult to maintain, and the recurrence rate after surgery is high.20,21 Even with release of the medial deltoid ligament of the ankle, tightening of the lateral collateral ligament of the ankle, and even the extension of the medial external fixator, the recurrence rate of the TT angle is still high. An open wedge osteotomy in the low tibia improves clinical symptoms, but the TT angle does not change significantly.22 However, with the correction of the subtalar alignment, the displacement of the talus centre, and the recovery of the hindfoot alignment, the TT angle can be significantly reduced. The degree of talus centre displacement and the degree of hindfoot varus are important factors affecting the reduction of TT angle after supramalleolar correction. Therefore, it is necessary to assess the talus centre position and hindfoot alignment. We proposed a novel surgical approach combining supramalleolar osteotomy and submalleolar osteotomy to jointly correct lower limb alignment and treat varus ankle arthritis with increased TT angle. Anteroposterior and lateral radiographs of the weightbearing ankle were performed before and one year after surgery for imaging evaluation. The TAS angle, TLS angle, and TT angle were measured. The clinical efficacy was evaluated according to the AOFAS scoring system and pain VAS. We found that SMOT combined with calcaneal osteotomy significantly improved varus ankle arthritis with a significant reduction in TT angle.
The goal of osteotomy for varus ankle arthritis is to stabilize the ankle joint and correct abnormal alignment.23 This shifts the abnormal stress point to the non-degenerative area of the articular cartilage, relieving painful symptoms. This stress redistribution, or transfer of the load-bearing axis, can be achieved by calcaneal osteotomy. The calcaneal osteotomy was first reported by Gleich in 189324 to correct the heel valgus deformity of flat foot deformity and restore normal alignment of the hindfoot.25 In 1955, Dwyer26 first reported the lateral approach of calcaneal closure wedge-shaped osteotomy for calcaneal varus deformity.26 Numerous clinical studies have shown that calcaneal osteotomy can change the alignment of the achilles tendon and correct the alignment of the hindfoot.27 Therefore, calcaneal osteotomy was applied to correct the alignment of the lower limb, and was combined with SMOT to treat varus ankle arthritis with increased TT angle in this study.
Park et al16 proposed that subtalar arthrodesis combined with supramalleolar osteotomy in the treatment of advanced varus ankle osteoarthritis with hindfoot valgus has a favourable clinical and imaging improvement effect. Mosca et al28 noted that subtalar arthrodesis can restore flexibility of the foot and ankle complex to some extent. Sun et al29 have also shown that minimally invasive subtalar arthrodesis is safe and effective. However, subtalar arthrodesis may cause hazards such as infection, limited joint mobility, and muscle atrophy. Therefore, we opted for an osteotomy of the calcaneus to correct the hindfoot alignment.
There are also some limitations in this study. First, this study is a retrospective study, and there are some biases that may affect the surgical outcome. Secondly, this study is the result of a single-centre study, and the overall sample size is small, and the sample size needs to be expanded in subsequent studies.
Our data demonstrated that SMOT combined with calcaneal osteotomy significantly improved varus ankle arthritis with a significant reduction in TT angle. This suggests that SMOT combined with calcaneal osteotomy is a practical surgical approach for varus ankle arthritis with excessive TT angle.
Take home message
- Varus ankle arthritis with excessive talar tilt (TT) angle often had unsatisfactory outcomes after supramalleolar osteotomy (SMOT) surgery.
- Adjuvant correction of the hind foot component may contribute to TT angle.
- This study suggests that SMOT combined with calcaneal osteotomy was a practical surgical approach for varus ankle arthritis with excessive TT angle.
Author contributions
H. Tian: Data curation, Methodology, Project administration, Writing – review & editing
W. Zheng: Data curation, Methodology, Project administration, Writing – review & editing
Y. Li: Data curation, Methodology, Project administration, Writing – review & editing
X. Wang: Data curation, Funding acquisition, Methodology, Project administration, Writing – review & editing
Funding statement
This study was financed by Shaanxi Key Research and Development plan (2024SF-YBXM-202).
ICMJE COI statement
The authors have no conflicts of interest to disclose.
Data sharing
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. The data that support the findings for this study are available to other researchers from the corresponding author upon reasonable request.
Ethical review statement
This study was performed in accordance with the Declaration of Helsinki and approved by the institutional research committee of the hospital where corresponding author works (Protocol Number 20240127). All the patients have signed informed consent forms.
Open access funding
The open access fee was funded by Shaanxi Key Research and Development plan (2024SF-YBXM-202).
© 2025 Tian et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/
Data Availability
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. The data that support the findings for this study are available to other researchers from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. The data that support the findings for this study are available to other researchers from the corresponding author upon reasonable request.