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Varus ankle with arthritis in young patient

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  1. Sep 26, 2011

    Yes, this is a serious problem for a young patient. I think the MR appearances reflect OA rather than AVN unless there are high risk features for the latter.

    If she has a reasonable range of movement I'd probably scope her first to check the joint and debride any synovitis/debris then do a supramalleolar osteotomy (Tanaka Y et al Low tibial osteotomy for varus-type osteoarthritis of the ankle JBJS (Br) 2006; 88B:909-13; Harstall R et al Supramalleolar Lateral Closing Wedge Osteotomy for the Treatment of Varus Ankle Arthrosis. Foot Ankle Int 2007; 28(5):542-8; Pagensteert GI et al Realignment Surgery as Alternative Treatment of Varus and Valgus Ankle Osteoarthritis CORR 2007; 462:156-68). You need to assess the lateral ligaments as they may need reconstruction. Lee described doing the osteotomy through the calcaneum (FAI 2009; 30(6):475-80) but this patient's heel is in valgus if anything; I have only done calcaneal osteotomy for varus ankle OA when the heel was varus.

    Another option is joint distraction with a frame (Ploegmakers JJW et al Prolonged clinical benefit from joint distraction in the treatment of ankle osteoarthritis. Arthritis Cartilage 2005; 13:582-8; Tellisi N et al. Joint Preservation of the Osteoarthritic Ankle Using Distraction Arthroplasty Foot Ankle Int 2009; 30(4):318-25) into which one could incorporate an osteotomy. Ploegmakers' group previously published earlier results including a smal "RCT" but I have been unable to find further reports of the RCT and I have no personal experience of the technique. Distraction can increase range of movement. However, if the ankle is very stiff she would probably be better with a fusion and hopefully this amount of deformity could be accommodated arthroscopically.

    Great case, thanks