Supra-malleolar distal tibial osteotomy: Medial opening wedge with Arthrex plate
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A supra-malleolar tibial osteotomy is used for either a varus or valgus tibial malalignment in the presence of a salvageable osteo-arthritic joint (or indeed before the ankle has become arthritic). It can also be used with a normal diaphyseal alignment but intra-articular angular deformity.
What is a salvageable joint and what is not is not well defined in the literature. The upper limit of deformity that responds well to the technique is also not defined. It is not simply to be regarded as analogous to a proximal tibial osteotomy in an early arthritic knee which is a more commonly indicated operation with a much greater body of evidence behind it.
The principle (as with proximal tibial osteotomies) is to preferentially load healthy articular surface and redistribute weight away from the deficient parts of the joint. The most common scenario is the varus joint and this can be corrected either with a medial opening wedge or a lateral closing wedge. The medial wedge will stretch the medial soft tissues and the use of an appropriately sized tibial plate does nothing to lessen this.
If used as an arthritic joint sparing salvage procedure patients will have mild or moderate ankle arthritis only and symptoms commensurate with this. The predictable and in general long lived and highly functional results to be expected after an ankle fusion should not be disregarded in this patient subgroup.
Author: Mark Herron FRCS (Tr & Orth).
Institution: The Wellington Hospital, London, UK.
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