Measure the angle of the distal tibial articular surface⁷ (normal, 91° to 93°), the tibiotalar angle⁸ (normal, 91.5° ± 1.2°), and the tibial lateral surface angle^9,10 (normal, 83° ± 3.6°¹¹) on weight-bearing radiographs.

Distinguish two groups of patients according to the location of the deformity:

• ○ valgus deformity below the ankle joint

• ○ valgus deformity of the distal tibial articular surface angle

Distinguish two different types of impingement:

• ○ calcaneofibular impingement—i. e., tenderness under the tip of the fibula (Fig. 1)

• ○ anterior ankle joint impingement—i. e., painful restriction of passive dorsiflexion (Fig. 2)

Determine the treatment using the decisional algorithm in Figure 3.

Plan the surgical correction on anteroposterior, lateral, and hindfoot radiographs (Figs. 4-A, 4-B, and 4-C):

• ○ Draw the proximal plane perpendicular to the medial tibial cortex, exiting the lateral cortex slightly proximal to the former growth plate^12-14.

• ○ Draw the distal plane on the basis of the desired amount of correction. The height of the wedge to be removed is determined using the equation: tan α1 × W, where α1 is the amount of valgus deformity with the desired overcorrection and W is the width of the distal part of the tibia¹⁵.

• ○ Plan for an overcorrection of 3° to 5°.

• ○ In patients with anterior ankle impingement, measure the tibial lateral surface angle to plan the additional anterior closing-wedge osteotomy of the distal part of the tibia in the sagittal plane (Figs. 5 and 6).

Use spinal or general anesthesia for the reconstruction.

Use a single prophylactic dose of intravenous antibiotics within twenty minutes prior to the start of surgery.

Position the patient supine on a radiolucent operating table.

Apply a tourniquet on the ipsilateral thigh and exsanguinate the limb prior to inflating the tourniquet.

Use a medial approach to expose the distal part of the tibia posterior to the greater saphenous vein and the saphenous nerve (Fig. 7).

Protect the posterior tibial tendon, which lies directly behind (posterior to) the medial malleolus. Retract the tendon posteriorly without opening the tendon sheath to visualize the dorsal surface of the distal part of the tibia.

Determine the plane of the osteotomy under fluoroscopy. Place a Kirschner wire from the medial to the lateral cortex, exiting the bone slightly proximal to the former growth plate, respecting the anatomical axis of the ankle joint (anteromedial to posterolateral).

Use a second Kirschner wire to mark the second cut based on the preoperative planning (Fig. 8).

For biplanar osteotomies in ankles with anterior and subfibular impingement, use anterior and medial closing-wedge osteotomies.

Incise the periosteum at the level of the osteotomy and elevate it off the bone using a scalpel or periosteal elevator (Fig. 9).

Perform the cuts with a wide saw blade and continuous irrigation.

Pay attention to preserving the lateral tibial cortex as a hinge.

Remove the bone wedge (Fig. 10) and close the osteotomy.

Use rigid plate fixation with interlocking screws (such as TIBIAXYS; Integra LifeSciences/Newdeal, Lyon, France) to secure the correction (Figs. 11 through 12-C). Alternatively, a 3.5-mm LCP T-plate (distal radial plate) can be used.

Fix the plate first distally. Then apply compression (manually or with a compression device [Integra LifeSciences/Newdeal]) to the osteotomy site and secure the plate proximally.

Close the periosteum over the osteotomy site with number-2-0 absorbable sutures.

Check the congruency of the ankle mortise under fluoroscopy after correction of the distal tibial joint surface.

Osteotomize the fibula in cases of joint incongruency due to inadequate length or position of the fibula (i.e., if the fibula is too short or there is increased lateral clear space), or if the talus does not follow the medial malleolus (increased medial clear space)^12,16,17.

Expose the distal part of the fibula through a longitudinal, slightly curved incision.

Visualize the anterior syndesmosis at the distal end of the incision.

The lateral branch of the sural nerve and the short saphenous vein run posterior to the line of the incision and are usually not seen during this procedure.

Incise and mobilize the periosteum carefully with a scalpel or the periosteal elevator.

Using an oscillating saw, create an oblique cut starting from the insertion of the anterior syndesmosis of the fibula and exiting the fibula posteriorly (Fig. 13).

Adjust the length of the fibula under fluoroscopic control until a congruent joint is achieved (equal medial and lateral clear spaces), and secure the correction with a one-third tubular plate.

Clinically reassess the alignment of the heel after the supramalleolar correction.

Add an osteotomy of the calcaneus when the heel remains in a valgus position after the supramalleolar correction¹⁸.

Use a lateral approach to the calcaneus. Place the incision approximately 1 cm posterior and parallel to the peroneal tendons (Fig. 14).

Pay attention to avoiding the branches of the sural nerve.

Insert a small Hohmann retractor on the plantar aspect of the calcaneus and a second one over the calcaneus in the dorsal concavity.

Use an oscillating saw to create the osteotomy.

Medialize the tuberosity with a Hohmann retractor after mobilizing it with a laminar spreader (Fig. 15).

Secure the correction with one or two cannulated 5.5 or 7.5-mm screws.

Consider a plantar flexion osteotomy of the first cuneiform¹⁹ in a patient with fixed forefoot supination.

Incise the skin at the dorsal aspect of the first cuneiform. Place the incision medial to the extensor hallucis longus tendon.

Using a small saw blade, complete the osteotomy in the oblique direction from the distal and dorsal aspect of the foot to the proximal and plantar aspect.

Greenstick the plantar cortex and plantar flex the medial column gently.

Use the wedge of bone obtained from the correction of the tibia to fill the resulting gap.

Secure the correction with cannulated 3.0-mm screws placed from proximal dorsal to distal plantar.

Close all incisions with interrupted, nonabsorbable sutures and apply a well-padded short leg splint to support the foot in a neutral position for two days.

Allow partial weight-bearing with the ankle protected in a splint at night and in a walking boot during the day for eight weeks.

After eight weeks, allow full weight-bearing and initiate physiotherapy.

Lateral ankle joint impingement with valgus malalignment of the tibiotalar joint line

Anterior ankle joint impingement

Early stages of lateral ankle joint arthritis

Valgus malalignment below the ankle joint line

Remaining subtalar valgus deformity after correction of the supramalleolar alignment

Supinated forefoot after correction of the supramalleolar alignment (preexisting deformity may be amplified by the correction of the hindfoot)

Collapse of the medial arch of the foot

Concomitant flatfoot deformity

Acute localized soft-tissue infection

Severe vascular or neurological deficiency in the affected extremity

Neuropathic disorders (e.g., Charcot foot)

Severe hindfoot instability that cannot be stabilized

End-stage ankle joint arthritis

Altered bone quality (due to medication, large cysts, or osteopenia or osteoporosis)

Age of more than seventy years

Insulin-dependent diabetes

Smoking

Tendon laceration. Protect the extensor tendons and the posterior tibial tendon by subperiosteal placement of a Hohmann retractor during the saw cut. If the posterior tibial tendon is extensively scarred due to the previous procedures, expose the tendon through a minimal incision and then retract it posteriorly¹³.

Accidental saw cut through the lateral cortex. Particularly in biplanar corrections, it may not be possible to preserve the lateral cortex as a hinge for the medial closing-wedge osteotomy. This increases the risk of malrotation or secondary loss of correction. Mark the rotation of the distal fragment prior to the osteotomy with an electrocautery to avoid malrotation. Secondary loss of correction is avoided by the use of implants with interlocking screws or adding a second plate in a second plane.

Malpositioning of the joint line. Use careful preoperative planning and fluoroscopy during the surgery to ensure proper closure of the osteotomy site and joint congruency.

Sural nerve injury. Expose the lateral wall of the calcaneus carefully to avoid damage to the nerve. In our experience, it is usually not necessary to expose the nerve.

Postoperative irritation of the peroneal tendons and wound-healing problems. After the displacement, impact the lateral rim of the tuberosity to reduce the bleeding surface of the bone and soft-tissue strain.

In our original paper²⁰, the osteotomy of the fibula was not included. Newer findings suggest that a main risk factor for failure after a supramalleolar osteotomy is an incongruent ankle joint^12,17. In the future, we will pay more attention to the length and position of the fibula and consider an additional corrective fibular osteotomy in patients with an incongruent joint after the correction of the distal articular surface angle.

Overcorrection after surgical treatment for clubfoot deformity has been reported to occur in up to 67% of patients¹. Furthermore, 70% of the inferior results after surgical correction of clubfoot deformity are reported to be due to overcorrection.

Not recognizing the origin of the deformity may lead to inappropriate flatfoot surgery.

The closing-wedge type of osteotomy may not be adequate for large deformities as this may lead to excessive translation of the calcaneal tuberosity. In these cases, the use of a dome-shaped osteotomy should be considered.

Patients with an overcorrected clubfoot frequently present with a flatfoot. It is currently unknown how aggressively medial arch collapse should be addressed in these patients.