Advertisement

Posterior closing wedge tibial osteotomy to correct iatrogenic anterior talus dislocation: A surgical case

Open AccessPublished:July 14, 2022DOI:https://doi.org/10.1016/j.fastrc.2022.100226

      Abstract

      A 67-year-old man presented with persistent ankle pain and instability nine months post excision of anterodistal tibial osteophytes. Radiographs confirmed anterior dislocation of the talus secondary to resection of the articular surface of the tibia. Tibiotalar arthrodesis and total ankle arthroplasty were considered, but joint preservation was desirable due to the patient's active lifestyle and the healthy condition of the remaining articular surface. The patient underwent previously unreported 10-degree posterior closing wedge osteotomy of the distal tibia effectively reducing the subluxation, stabilized the joint, and preserving tibiotalar motion. At 8 months post-op, the patient had resumed his active lifestyle.

      Keywords

      Level of Clinical Evidence

      Introduction

      Surgical intervention for ankle arthritis is performed with the primary goal of reducing pain within the tibiotalar joint. The gold standard for intervention at the late stage of degenerative joint disease is arthrodesis, although similar rates of patient satisfaction has been shown with total ankle arthroplasty.
      • Shih C.L.
      • Chen S.J.
      • Huang P.J.
      Clinical outcomes of total ankle arthroplasty versus ankle arthrodesis for the treatment of end-stage ankle arthritis in the last decade: a systematic review and meta-analysis.
      ,
      • Thomas R.H.
      • Daniels T.R.
      Ankle arthritis.
      Whenever possible, preservation of the natural articular surface is associated with better outcomes. This option is limited, however, by the extent of degeneration at the joint and is dependent upon some preservation of the articular surface.
      • Knupp M.
      • Stufkens S.A.
      • Bolliger L.
      • Barg A.
      • Hintermann B.
      Classification and treatment of supramalleolar deformities.
      Supramalleolar osteotomies have well documented success rates in the treatment of early and midstage valgus and varus arthritic deformities of the ankle,
      • Knupp M.
      • Stufkens S.A.
      • Bolliger L.
      • Barg A.
      • Hintermann B.
      Classification and treatment of supramalleolar deformities.
      but a review of literature yielded no peer-reviewed cases of a posteriorly based closing wedge osteotomy of the distal tibia.

      Case report

      A 67-year-old man presented to the ambulatory clinic with the chief complaint of unresolved left ankle pain nine months status post osteophyte excision at an outside hospital. The patient, frustrated by his inability to tolerate his hobbies of cycling and recreational basketball, sought a second opinion regarding his ankle arthritis. On physical exam, there was instability of the ankle with significant anterior drawer and symmetric range of motion when compared to the right. Radiographs at that time showed the talus to be dislocated anteriorly out of the ankle mortise (Fig. 1a) with reduction achievable when a posteriorly directed force on the leg was combined with anterior traction on the foot (Fig. 1b). Comparison films from before osteophyte excision showed the extent of tibial articular surface resection (Fig. 1c). Both tibiotalar arthrodesis and joint-preserving surgery were discussed with the patient. Despite fusion having a more predictable outcome, patient and surgeon agreed upon joint preserving intervention given the overall healthy appearance of the remaining articular surface and the potential to maintain range of motion.
      Fig 1
      Fig. 1Lateral ankle radiographs pre (1c) and post (1a, 1b) excision of osteophytes. Note the anterior displacement of the talus relative to the distal tibia in the non-stress view (a) and the preservation of the articular surface when the dislocation is reduced under stress (b).
      At the time of surgery, a small medial incision was made at the level of the insertion of the gastrocnemius tendon. With superficial and deep soft tissues protected, the gastrocnemius tendon was released across and the wound was irrigated and closed. A posterolateral incision at the ankle was made and the sural nerve was identified and protected. The interval between the peroneal and flexor hallucis longus musculature was identified and developed allowing access to the posterior aspect of the tibia. Two, 2.0 drill bits were used to determine the trajectory of the 10-degree wedge to be taken from the posterior tibia (Fig. 2a). Upon confirming the trajectory on C-arm, an oscillating saw was utilized to cut and remove the wedge (Fig. 2b). A 10 degree, posteriorly based wedge was also cut from the fibula at this time. The distal fragment of the tibia was then approximated to the proximal fragment (Fig. 3). The osteotomies were stabilized with a distal tibia locking plate and a 1/3 tubular plate for the fibula (Fig. 4). An external fixator was applied at this point with one pin in the calcaneus and an anterior pin in the tibia to place a posteriorly directed force on the calcaneus to maintain reduction. Prior to closing, local bone graft from the removed wedge was applied to the wound to promote union of the osteotomies.
      Fig 2
      Fig. 2Radiographs showing the planned osteotomies with screws (2a) and the tibia post wedge removal (2b).
      Fig 3
      Fig. 3Lateral radiograph showing the approximation of the proximal and distal osteotomy sites.
      Fig 4
      Fig. 4Anteroposterior (4a) and lateral (4b) intraoperative radiographs of the osteotomy site post reduction and fixation.
      The patient was seen weekly in clinic for the first month to assess reduction and adjust the external fixator to increase traction. Radiographs at 6 weeks post-op confirmed that the reduction had held, and the external fixator was removed. The patient was transitioned to a CAM boot with strict non-weight bearing precautions at this time but was encouraged to work on range of motion outside of the boot. At ten weeks, he was allowed 50% weightbearing in the CAM boot, and at three months, the patient was released to full weight bearing as tolerated. At his 8 month follow up, the patient had symmetric range of motion in both ankles and reported he had completed his annual 450 mile bike ride and was able to play basketball with his grandson. The patient was last examined 6 years post-operation (age 73) at which time he continued to enjoy his physical hobbies. On terminal radiographs, the patient had mild arthritic changes at the lateral aspect of the ankle at that time but was without ankle complaints (Fig. 5). During an interview at 8 years post-operation, the patient reported that he was able to perform 90% of the activities he desired and was mostly limited by hip arthritis. At 75 years of age, the patient is playing basketball, hiking uneven terrain, and cycling with minimal difficulty. His Foot and Ankle Outcomes
      • Jon K.
      Foot and Ankle Outcomes Score Calculator.
      score was 93% with categorical breakdown available in Table 1.
      Fig 5
      Fig. 5Lateral (5a) and anteroposterior (5b) radiographs of the healed osteotomy site at the six-year post-operative appointment.
      Table 1Categorical breakdown of patient Foot and Ankle Outcomes score at 8 years postoperation.
      OverallSymptoms + StiffnessPainFunction/ Daily LivingFunction/ Sports and RecreationQuality of Life
      93%96%92%97%90%75%

      Discussion

      At the time of presentation, the patient had a non-functional ankle joint secondary to chronic anterior dislocation of the talus. Interventions primarily considered at this point were ankle arthrodesis and joint preserving surgery. Alternatives discussed included non-operative treatment and referral for total ankle arthroplasty. At the time of intervention, total ankle arthroplasty was considered, but arthrodesis was the more favorable non-joint preserving option due to higher predictability of outcomes and similar patient satisfaction.
      • Morash J.
      • Walton D.M.
      • Glazebrook M.
      Ankle arthrodesis versus total ankle arthroplasty.
      Anecdotal evidence at the time saw higher rates of revision associated with total ankle replacement as compared to ankle arthrodesis, phenomena that would later be supported by retrospective studies.
      • Barg A.
      • Wimmer M.D.
      • Wiewiorski M.
      • Wirtz D.C.
      • Pagenstert G.I.
      • Valderrabano V.
      Total ankle replacement.
      ,
      • Gramlich Y.
      • Neun O.
      • Klug A.
      • Buckup J.
      • Stein T.
      • Neumann A.
      • Fischer S.
      • Abt H.P.
      • Hoffmann R.
      Total ankle replacement leads to high revision rates in post-traumatic end-stage arthrosis.
      It should be noted that later studies showed higher complication rates in ankle arthrodesis and no significant difference in patient satisfaction between the two interventions.
      • Lawton C.D.
      • Butler B.A.
      • Dekker 2nd, R.G.
      • Prescott A.
      • Kadakia A.R.
      Total ankle arthroplasty versus ankle arthrodesis-a comparison of outcomes over the last decade.
      ,
      • Thomas R.H.
      • Daniels T.R.
      Ankle arthritis.
      Non-operative intervention was also less favorable as the status of the patient's joint was destined to decline if the structural instability was not corrected. Tibiotalar fusion was considered as the more traditional approach to the patient's pathology with the benefit of predictable and well researched outcomes.
      • Kusnezov N.
      • Dunn J.C.
      • Koehler L.R.
      • Orr J.D.
      Anatomically contoured anterior plating for isolated tibiotalar arthrodesis: a systematic review.
      However, the overall healthy appearance of the patient's joint space and articular surface made the prospect of joint-preserving surgery a worthwhile consideration. When considering the wedge osteotomy, similar principles utilized in supramalleolar osteotomies were applied including complete stress radiographs and preoperative mapping of the osteotomy sites.
      • Lacorda J.B.
      • Jung H.G.
      • Im J.M.
      Supramalleolar distal tibiofibular osteotomy for medial ankle osteoarthritis: current concepts.
      Ultimately, the patient's quality of life was highly dependent upon maintaining his ankle mobility in order to support a highly active lifestyle. Ankle arthrodesis was a reasonable alternative, but the cost of fusion would be a significant reduction in range of motion and the forfeit of a grossly well-preserved articular surface. Prior to surgery, the consensus among colleagues with whom the case was shared was in favor of joint preservation with a posterior closing wedge, despite the absence of documented cases in the literature. Taking all of this into account, the decision was made to attempt joint preserving surgery with the understanding that refractory ankle instability could result in the need for future tibiotalar fusion. The patient tolerated both the procedure and recovery very well and was able to resume activities he was unable to tolerate prior to the osteophyte excision.

      Declaration of Competing Interests

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

      Informed Patient Consent

      Complete informed consent was obtained from the patient for the publication of this study and accompanying images.

      References

        • Shih C.L.
        • Chen S.J.
        • Huang P.J.
        Clinical outcomes of total ankle arthroplasty versus ankle arthrodesis for the treatment of end-stage ankle arthritis in the last decade: a systematic review and meta-analysis.
        J Foot Ankle Surg. 2020; 59 (Sep-OctEpub 2020 Jul 21. PMID: 32709528): 1032-1039https://doi.org/10.1053/j.jfas.2019.10.008
        • Thomas R.H.
        • Daniels T.R.
        Ankle arthritis.
        J Bone Joint Surg Am. 2003 May; 85 (PMID: 12728047): 923-936https://doi.org/10.2106/00004623-200305000-00026
        • Knupp M.
        • Stufkens S.A.
        • Bolliger L.
        • Barg A.
        • Hintermann B.
        Classification and treatment of supramalleolar deformities.
        Foot Ankle Int. 2011 Nov; 32: 1023-1031https://doi.org/10.3113/FAI.2011.1023. PMID: 22338950
        • Jon K.
        Foot and Ankle Outcomes Score Calculator.
        OrthoToolKit. 2022;
        • Morash J.
        • Walton D.M.
        • Glazebrook M.
        Ankle arthrodesis versus total ankle arthroplasty.
        Foot Ankle Clin. 2017 Jun; 22: 251-266https://doi.org/10.1016/j.fcl.2017.01.013. PMID: 28502347
        • Barg A.
        • Wimmer M.D.
        • Wiewiorski M.
        • Wirtz D.C.
        • Pagenstert G.I.
        • Valderrabano V.
        Total ankle replacement.
        Dtsch Arztebl Int. 2015 Mar 13; 112 (PMID: 25837859; PMCID: PMC4390826): 177-184https://doi.org/10.3238/arztebl.2015.0177
        • Gramlich Y.
        • Neun O.
        • Klug A.
        • Buckup J.
        • Stein T.
        • Neumann A.
        • Fischer S.
        • Abt H.P.
        • Hoffmann R.
        Total ankle replacement leads to high revision rates in post-traumatic end-stage arthrosis.
        Int Orthop. 2018 Oct; 42 (Epub 2018 Mar 20. PMID: 29560526): 2375-2381https://doi.org/10.1007/s00264-018-3885-z
        • Lawton C.D.
        • Butler B.A.
        • Dekker 2nd, R.G.
        • Prescott A.
        • Kadakia A.R.
        Total ankle arthroplasty versus ankle arthrodesis-a comparison of outcomes over the last decade.
        J Orthop Surg Res. 2017 May 18; 12 (PMID: 28521779; PMCID: PMC5437567): 76https://doi.org/10.1186/s13018-017-0576-1
        • Kusnezov N.
        • Dunn J.C.
        • Koehler L.R.
        • Orr J.D.
        Anatomically contoured anterior plating for isolated tibiotalar arthrodesis: a systematic review.
        Foot Ankle Spec. 2017 Aug; 10 (Epub 2017 Mar 26. PMID: 28345364): 352-358https://doi.org/10.1177/1938640017700974
        • Lacorda J.B.
        • Jung H.G.
        • Im J.M.
        Supramalleolar distal tibiofibular osteotomy for medial ankle osteoarthritis: current concepts.
        Clin Orthop Surg. 2020 Sep; 12 (Epub 2020 Aug 19. PMID: 32904071; PMCID: PMC7449861): 271-278https://doi.org/10.4055/cios20038