Total ankle replacement for end-stage ankle arthritis with talar varus malalignment of ≥10° can achieve satisfactory outcomes in the ankle joint, and ≥10° of talar varus malalignment should not be considered a contraindication for surgery.
Step 1: Preoperative Assessment and Planning
Conduct a thorough clinical and radiographic evaluation of the entire lower extremity.
Step 2: Surgical Assessment
In the operating room, conduct a physical examination prior to and following ankle exposure to determine the ancillary procedures required.
Step 3: Medial Soft-Tissue Release (Pes Cavus Correction)
Proceed with tendon and soft-tissue release as needed to correct pes cavus deformity and improve range of motion.
Step 4: Correction of Varus Talar Deformity
Correct varus talar deformity via a standard resection of the ankle joint osteophytes, starting laterally and finishing medially.
Step 5: Posterior Tibial Tendon Transfer to the Peroneus Brevis
Consider transfer of the posterior tibial tendon to the peroneus brevis to help maintain correction of the varus deformity.
Step 6: Ankle Replacement
Once you determine that the talar varus is correctable and you have prepared the posterior tibial tendon for transfer, perform the total ankle replacement.
Step 7: Foot Evaluation and Ancillary Procedures
Evaluate the rest of the foot and perform any required ancillary procedures; most often a dorsiflexion osteotomy of the first metatarsal is necessary to correct forefoot valgus, which is commonly seen in forefoot-driven cavovarus deformities.
Patients with preoperative coronal plane varus tibiotalar deformities of ≥10° who underwent total ankle replacement have shown significant improvement in clinical outcome scores at the time of mid-term follow-up.
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