Strategies in Trauma and Limb Reconstruction

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VOLUME 19 , ISSUE 2 ( May-August, 2024 ) > List of Articles

CLINICAL TECHNIQUE

Oblique Dorsiflexion Osteotomy of the Distal Tibia for Fixed Ankle Equinus: Surgical Technique

Ramiro Olleac, Fernando Farfan, Lucas Acosta, Sabrina Campero, Mohan V Belthur

Keywords : Burns, Equinus deformity, Flat topped talus, Oblique osteotomy, Supramalleolar osteotomy

Citation Information : Olleac R, Farfan F, Acosta L, Campero S, Belthur MV. Oblique Dorsiflexion Osteotomy of the Distal Tibia for Fixed Ankle Equinus: Surgical Technique. 2024; 19 (2):104-110.

DOI: 10.5005/jp-journals-10080-1619

License: CC BY-NC 4.0

Published Online: 14-08-2024

Copyright Statement:  Copyright © 2024; The Author(s).


Abstract

Aim: There are significant challenges in the treatment of a severe rigid ankle equinus caused by a flat-topped talus, arthrogryposis, burn sequelae, or extensive scarring. Conventional approaches, such as soft tissue releases, often fail due to joint incongruence or compromised soft tissues, thereby necessitating supramalleolar osteotomies. The classic transverse supramalleolar osteotomy (TSO) of the distal tibia can lead to secondary anterior translation of the centre of rotation of the ankle and alters mechanical and anatomical axes. An alternative technique involves an oblique closing wedge osteotomy of the distal tibia, with a fulcrum near the ankle joint. This technical note delineates the planning parameters and procedural steps for the oblique dorsiflexion osteotomy of the distal tibia (ODODT). Method: Using an anterior approach to the distal tibia, the “alpha angle,” which determines the size of the closing wedge required for the foot to be plantigrade, is resected with a fulcrum at the most posterior part of the ankle joint, ensuring that the posterior cortex remains intact. The inclination of this resected wedge is planned preoperatively and is referred to as the “beta angle.” This aims to equalise the lengths on both sides of the osteotomy. For osteotomy fixation, 2 or 3 cannulated screws in lag mode are employed. Postoperatively, a short cast boot is used for 6 weeks. Results: The ODODT is a salvage solution for severe rigid ankle equinus when first-line foot and ankle procedures are impractical due to tibiotalar incongruence or poor soft tissues. Advantages include minimal translation of the centre of rotation of the ankle, excellent stability when the posterior cortex remains intact, avoidance of large internal fixation devices, and cost-effectiveness, making it suitable for low-resource settings.


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  1. Hur GY, Rhee BJ, Ko JH, et al. Correction of postburn equinus deformity. Ann Plast Surg 2013;70(3):276–279. PMID: 23340460.
  2. Al-Aubaidi Z, Lundgaard B, Pedersen NW. Anterior distal tibial epiphysiodesis for the treatment of recurrent equinus deformity after surgical treatment of clubfeet. J Pediatr Orthop 2011;31(6):716–720. DOI: 10.1097/BPO.0b013e31822109b6.
  3. Zargarbashi R, Abdi R, Bozorgmanesh M, et al. Anterior distal hemiepiphysiodesis of tibia for treatment of recurrent equinus deformity due to flat-top talus in surgically treated clubfoot. J Foot Ankle Surg 2020;59(2):418–422. DOI: 10.1053/j.jfas.2019.08.018.
  4. Ebert N, Ballhause TM, Babin K, et al. Correction of recurrent equinus deformity in surgically treated clubfeet by anterior distal tibial hemiepiphysiodesis. J Pediatr Orthop 2020;40(9):520–525. DOI: 10.1097/BPO.0000000000001609.
  5. Nelman K, Weiner DS, Morscher MA, et al. Multiplanar supramalleolar osteotomy in the management of complex rigid foot deformities in children. J Child Orthop 2009;3(1):39–46. DOI: 10.1007/s11832-008-0157-2.
  6. Sen C, Kocaoglu M, Eralp L, et al. Correction of ankle and hindfoot deformities by supramalleolar osteotomy. Foot Ankle Int 2003;24(1):22–28. DOI: 10.1177/107110070302400103.
  7. Mosca VS. Bone procedures. In: Principles and management of pediatric foot and ankle deformities and malformations. 2014th ed. Wolters Kluwer Health; 2014; p. 352.
  8. Handelsman JE, Weinberg J. Supramalleolar wedge osteotomy: A method of correcting fixed equinus and associated deformities in children. The Foot 2005;15(1):33–39. DOI: 10.1016/j.foot.2004.11.001.
  9. Napiontek M, Nazar J. Tibial osteotomy as a salvage procedure in the treatment of congenital talipes equinovarus. J Pediatr Orthop 1994;14(6):763–767. DOI: 10.1097/01241398-199414060-00014.
  10. Malik SS, Knight R, Ahmed U, et al. Role of a tendon transfer as a dynamic checkrein reducing recurrence of equinus following distal tibial dorsiflexion osteotomy. J Pediatr Orthop B 2018;27(5):419–424. DOI: 10.1097/BPB.0000000000000500.
  11. Paley D. Ankle and foot considerations. In: Principles of deformity correction. Springer; 2002; p. 806.
  12. Mangone PG. Distal tibial osteotomies for the treatment of foot and ankle disorders. Foot Ankle Clin 2001;6(3):583–597. DOI: 10.1016/s1083-7515(03)00115-3.
  13. Chopra V, Stone P, Ng A. Supramalleolar osteotomies. Clin Podiatr Med Surg 2017;34(4):445–460. PMID: 28867052.
  14. Tanaka Y. The concept of ankle joint preserving surgery: Why does supramalleolar osteotomy work and how to decide when to do an osteotomy or joint replacement. Foot Ankle Clin 2012;17(4):545–553. DOI: 10.1016/j.fcl.2012.08.003.
  15. Teramoto T, Harada S, Takaki M, et al. The Teramoto distal tibial oblique osteotomy (DTOO): Surgical technique and applicability for ankle osteoarthritis with varus deformity. Strateg Trauma Limb Reconstr 2018;13(1):43–49. DOI: 10.1007/s11751-018-0307-0.
  16. Su Y, Nan G. Lateral closing isosceles triangular osteotomy for the treatment of a post-traumatic cubitus varus deformity in children. Bone Jt J 2016;98-B(11):1521–1525. DOI: 10.1302/0301-620X.98B11.37890.
  17. Sherman SL, Thompson SF, Clohisy JCF. Distal femoral varus osteotomy for the management of valgus deformity of the knee. J Am Acad Orthop Surg 2018;26(9):313–324. DOI: 10.5435/JAAOS-D-16-00179.
  18. Lamm BM, Stasko PA, Gesheff MG, et al. Normal foot and ankle radiographic angles, measurements, and reference points. J Foot Ankle Surg 2016;55(5):991–998. DOI: 10.1053/j.jfas.2016.05.005.
  19. Wagner E, Wagner P. Correction of sagittal plane deformity of the distal tibia. Foot Ankle Clin 2022;27(1):129–144. DOI: 10.1016/j.fcl.2021.11.011.
  20. Hamdy R, Katz A, Dumas É. Anterior hemiepiphysiodesis of the distal tibia: A step-by-step surgical technique guide. Strateg Trauma Limb Reconstr 2024;18(3):174–180. DOI: 10.5005/jp-journals-10080-1596.
  21. Warnock KM, Johnson BD, Wright JB, et al. Calculation of the opening wedge for a low tibial osteotomy. Foot Ankle Int 2004;25(11):778–782. DOI: 10.1177/107110070402501104.
  22. Kocaoğlu M, Eralp L, Atalar AC, et al. Correction of complex foot deformities using the Ilizarov external fixator. J Foot Ankle Surg. 2002;41(1):30–39. DOI: 10.1016/s1067-2516(02)80007-2.
  23. Freedman JA, Watts H, Otsuka NY. The ilizarov method for the treatment of resistant clubfoot: Is it an effective solution? J Pediatr Orthop 2006;26(4):432–437. DOI: 10.1097/01.bpo.0000226276.70706.0e.
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