Foot & Ankle International - September 2020 - 1122

938801
research-article2020

FAIXXX10.1177/1071100720938801Foot & Ankle InternationalChoi et al

Article

Low Tibial Valgization Osteotomy
for More Severe Varus Ankle Arthritis

Foot & Ankle International®
2020, Vol. 41(9) 1122--1132
© The Author(s) 2020
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https://doi.org/10.1177/1071100720938801
DOI: 10.1177/1071100720938801
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Jun Young Choi, MD1, Kun Woo Kim, MD1, and Jin Soo Suh, MD, PhD1

Abstract
Background: Low tibial valgization osteotomy with medial opening wedge (LTO) is generally indicated for ankle arthritis
with a small talar tilt (TT). We addressed the following research questions: the efficacy of LTO for more significant varus
ankle arthritis, the effect of additional inframalleolar correction followed by LTO, and the preoperative or operationrelated factors influencing postoperative TT decrease.
Methods: We retrospectively reviewed the radiographic and clinical findings of 31 patients with more significant varus
ankle arthritis (≥8 degrees) who underwent LTO or LTO plus inframalleolar correction. We grouped the included
patients according to combination with inframalleolar correction and postoperative decreased TT. Furthermore, a binary
logistic regression analysis was performed to determine the factors influencing postoperative TT decrease.
Results: Even though the mean TT was unchanged postoperatively (from 12.1 to 9.9 degrees, P = .052), clinical
parameters were significantly increased. In the group with concomitant inframalleolar correction, we found that TT was
more corrected (3.9 vs 1.8 degrees, P = .023) with a greater lateralization of the talar center and a greater correction
of the hindfoot alignment to valgus. The results of the binary logistic regression analysis showed a significant relationship
between postoperative decreased TT and preoperative talar center migration (P = .016), hindfoot alignment angle (P =
.033), hindfoot moment arm (P = .041), and hindfoot alignment ratio (P = .016).
Conclusion: LTO in more significant varus ankle arthritis could result in clinical improvement, although TT was not
significantly changed. We recommend adding inframalleolar correction after LTO for the patients with more significant
varus ankle arthritis.
Level of Evidence: Level III, comparative series.
Keywords: ankle, arthritis, varus deformity, low tibial osteotomy, supramalleolar osteotomy, talar center migration,
hindfoot alignment

The prevalence of ankle joint arthritis is approximately 1%
of the adult population,8,31 which is relatively low compared
with that of knee or hip arthritis. As the load-bearing area of
the ankle is smaller than that of the knee or hip, ankle arthritis can more easily lead to pain, dysfunction, and gait abnormality once it progresses.30
Low tibial valgization osteotomy with medial opening
wedge (LTO), also known as supramalleolar osteotomy, was
introduced by Takakura et al27 and is a useful realignment
procedure based on the pressure redistribution theory for
patients with ankle arthritis with varus malalignment.2,3,5,14,24
It is generally indicated for ankle arthritis in which the talar
tilt (TT) is small.28,29 Referring to the Takakura classification,27 LTO is recommended for stage 2 (narrowing of
medial joint space without subchondral bone contact) or
stage 3A (obliteration with subchondral bone contact limited

to the medial malleolus) ankle arthritis. Several authors1,17,20
reported that the TT would be unchanged after LTO. In this
scenario, asymmetric pressure concentration on the medial
talar dome can be worsened by an increased tibial anterior
surface angle (TAS) after LTO (Figure 1). However, in
our clinical practice, we have found plausible clinical and
radiographic results after LTO for more significant varus
ankle arthritis.
1

Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital,
Goyang-si, Gyeonggi-do, South Korea
Corresponding Author:
Jin Soo Suh, MD, PhD, Department of Orthopedic Surgery, Inje
University, Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si,
Gyeonggi-do 10380, South Korea.
Email: sjs0506@paik.ac.kr
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