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C OPYRIGHT 2015 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Weight-Bearing-Line Analysis in Supramalleolar

Osteotomy for Varus-Type Osteoarthritis
of the Ankle
Naoki Haraguchi, MD, Koki Ota, MD, Naoya Tsunoda, MD, Koji Seike, MD, Yoshihiko Kanetake, RT, and Atsushi Tsutaya, RT

Investigation performed at the Department of Orthopaedic Surgery, Tokyo Metropolitan Police Hospital, Tokyo, Japan

Background: We determined the preoperative and postoperative passing points of the mechanical axis of the lower limb
at the level of the tibial plafond using a new method involving a full-length standing posteroanterior radiograph that
includes the calcaneus (a hip-to-calcaneus radiograph) and correlated them to the clinical results after supramalleolar
osteotomy for ankle osteoarthritis.
Methods: We reviewed the hip-to-calcaneus radiographs of fty lower limbs of forty-one patients treated for lower limb
malalignment at our institution. The mechanical axis point of the ankle was the point at which the mechanical axis divides
the coronal length of the plafond, expressed as a percentage. Four independent observers performed all measurements
twice. Supramalleolar tibial osteotomy was performed in twenty-seven ankles (twenty-four patients) to treat moderate
varus-type osteoarthritis of the ankle. The mean follow-up period was 2.8 years (range, two to 5.3 years). Clinical
assessment was based on the American Orthopaedic Foot & Ankle Society (AOFAS) scale.
Results: Interobserver and intraobserver reliability in identifying the mechanical ankle joint axis point were very high. The
mean postoperative mechanical axis point was 50% (range, 13% to 70%) in ankles for which the preoperative point was 0%,
whereas the mean postoperative point was 81% (range, 48% to 113%) in ankles for which the preoperative point was >0%.
The mean change in AOFAS score was signicantly less for patients with a preoperative point of 0% than for those with a
preoperative point of >0% (p = 0.004). Improvement was signicantly greater in ankles with a postoperative mechanical
ankle joint axis point of 80% than in ankles with a postoperative mechanical ankle joint axis point of <60% (p = 0.030).
Conclusions: Traditional tibial correction resulted in great variation in the locations of the postoperative mechanical
ankle joint axis point. In ankles with the preoperative point more medial than the tibial plafond, the point was insufciently
moved to the lateral side, and the clinical outcomes were less satisfactory.
Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor
reviewed each revision of the article, and it underwent a nal review by the Editor-in-Chief prior to publication. Final corrections and clarications occurred during one or
more exchanges between the author(s) and copyeditors.

S
upramalleolar tibial osteotomy is an effective procedure
for the treatment of moderate ankle osteoarthritis1-10;
however, for some, the results are unsatisfactory. The
tibial correction angle has been determined on the basis of the
tibial ankle surface (TAS) angle, dened as the angle between
the tibial shaft and its distal joint surface on the anteroposterior
radiograph8. Such an osteotomy incorporates some overcor-
rection; however, the target TAS angle is based primarily on
experience and varies from one group to another3,6,8-10.
The purpose of an osteotomy for varus-type osteoar-
thritis of the ankle is to transfer the weight-bearing line from
the medial to the lateral side of the ankle. However, few studies
have analyzed the weight-bearing line both preoperatively and
postoperatively. Thus, the target mechanical axis point at the

Disclosure: None of the authors received psayments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any
aspect of this work. None of the authors, or their institution(s), have had any nancial relationship, in the thirty-six months prior to submission of this work,
with any entity in the biomedical arena that could be perceived to inuence or have the potential to inuence what is written in this work. Also, no author has
had any other relationships, or has engaged in any other activities, that could be perceived to inuence or have the potential to inuence what is written in this
work. The complete Disclosures of Potential Conicts of Interest submitted by authors are always provided with the online version of the article.

J Bone Joint Surg Am. 2015;97:333-9 d http://dx.doi.org/10.2106/JBJS.M.01327

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ankle remains unknown. The true mechanical axis of the lower
limb ought to be taken as a line from the center of the femoral
head to the lowest point of the calcaneus, not to the center of
the tibial plafond. To draw such a line, a radiograph that ex-
tends from the center of the femoral head to the lowest point of
the calcaneus, which must be clearly visualized, is needed.
We developed a full-length standing posteroanterior radio-
graph that includes the calcaneus (the hip-to-calcaneus radiograph)
for evaluation of the mechanical axis of the lower limb and hindfoot
alignment (Fig. 1; see Appendix). We describe a two-part study in
which we rst tested the reliability of identifying the true me-
chanical axis at the ankle by this radiographic method and then
used this method to determine the passing points of the mechanical
axis at the level of the tibial plafond preoperatively and postoper-
atively in patients with varus-type osteoarthritis of the ankle, with
correlation to the clinical results of supramalleolar osteotomy.
Materials and Methods
Part I. Reliability of Identifying the Mechanical Ankle Joint
Axis Point on the Hip-to-Calcaneus Radiograph
fter approval of our institutional review board, we reviewed fty radio-
A graphs of forty-one patients (nine were male and thirty-two were female)
treated for lower limb malalignment (mainly hindfoot malalignment) at our
institution in 2011 and 2012. Hip-to-calcaneus radiographs had been made for
each of the patients identied. The mean patient age (and standard deviation) at
the time the radiographs were made was 63.6 12.8 years (range, fteen to
eighty-six years). The causes of malalignment were osteoarthritis of the ankle
(twenty-seven limbs), atfoot deformity (nine limbs), osteoarthritis of the knee
(seven limbs), rheumatoid arthritis of the ankle (two limbs), neurologic dis-
order (two limbs), malunited fracture of the ankle (one limb), cavus foot (one
limb), and osteonecrosis of the talus (one limb).
W E I G H T - B E A R I N G -L I N E A N A LY S I S I N S U P R A M A L L E O L A R O S T E O T O M Y
F O R VA R U S -T Y P E A N K L E O S T E O A R T H R I T I S
Radiographic Measurement
By drawing a line from the center of the femoral head to the lowest point of the
calcaneus, the point at which the mechanical axis passes through the ankle is
determined. The mechanical ankle joint axis point is expressed as the ratio
representing the division of the coronal length of the plafond by the axis and is a
radiographic measure of the distance of this point from the medial corner of the
plafond. In some cases, the medial edge of the plafond appears indented, so the
top of the indent is considered the medial edge. The lateral edge is the lateral
end point of the thick line representing the subchondral bone of the plafond.
The medial and lateral edges of the tibial plafond are taken as 0% and 100%,
respectively; thus, a negative value indicates that the mechanical ankle joint axis
point is more medial than the medial corner of the plafond, and a value of
>100% indicates that the point is more lateral than the lateral edge of the
plafond. The Centricity picture archiving and communications system (Cen-
tricity Enterprise Web, version 3.0; GE Healthcare Biosciences, Piscataway, New
Jersey) is used to mark and assign a percentage value to the mechanical ankle
joint axis point on each radiograph.
Reproducibility of Our Radiographic Measurement Technique
All radiographs were analyzed by four observers: an orthopaedic fellow, a junior
attending surgeon, a senior attending surgeon, and a foot and ankle specialist,
with the calculated values recorded in a computer database. The measurements
were obtained in two sessions, with a four-week interval between sessions. Each
observer was blinded to the others measurements and to all patient data.
Intraclass correlation coefcients and their 95% condence intervals
(95% CIs) were used to assess intraobserver and interobserver reliability and
were derived from a mixed-effects model.
Part II. Weight-Bearing-Line Analysis in Supramalleolar
Osteotomy
Supramalleolar tibial osteotomy based on the TAS angle was performed in
twenty-seven ankles in twenty-four patients (ve men and nineteen women) with
relatively high activity demands who had moderate varus-type osteoarthritis of
Fig. 1
Technique for making the hip-to-calcaneus radio-
graph. The patient maintains a bipedal stance on
a radiolucent platform and faces the long lm
cassette. For the lowest point of the calcaneus to be
visualized on the radiograph, the cassette is slid
into position with its lower edge passing the edge of
the platform. The patients patella is placed for-
ward. The x-ray beam is centered on the knee of the
imaged leg from a distance of 2 m. Voltage and
current are 200 mA and 85 kV, respectively. It is
important to conrm on the radiograph that the
patella is centered between the femoral condyles.
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the ankle by an orthopaedic foot and ankle specialist with more than fteen years
of experience in foot and ankle reconstruction. The mean patient age at the time TABLE I Intraobserver Agreement Regarding Mechanical Ankle
of surgery was 64 8.6 years (range, forty-seven to seventy-four years), and the Joint Axis Point Measurements
mean follow-up period was 2.8 years (range, two to 5.3 years). Comorbidities
included hypertension (thirteen patients), hyperlipidemia (seven patients), car- Intraclass Correlation Coefcient
Observer (95% Condence Interval)
diovascular disease (two patients), Cushing disease (one patient), and asthma
(one patient). The mean body mass index (BMI) was 26.5 kg/m2 (range, 20.9 to 1 0.9948 (0.9941 to 0.9954)
36.0 kg/m2). Five patients were classied as obese (a BMI of >30 kg/m2).
Osteoarthritis of the ankle was graded according to the Takakura clas- 2 0.9941 (0.9935 to 0.9947)
8
sication system as modied by Tanaka et al. on the basis of weight-bearing 3 0.9927 (0.9920 to 0.9934)
anteroposterior ankle radiographs. According to this system, stage-1 osteoar- 4 0.9957 (0.9951 to 0.9964)
thritis involves no narrowing of the joint space but does involve early sclerosis
Combined 0.9930 (0.9924 to 0.9937)
and formation of osteophytes; stage 2 involves narrowing of the medial joint
space; stage 3A involves obliteration of the medial joint space, with subchondral
bone contact limited to the medial malleolus; stage 3B involves subchondral
bone contact extending to the roof of the dome of the talus; and stage 4 involves as the angle between the mechanical axis of the femur and that of the tibia. We
obliteration of the whole joint space with complete bone contact. Three of the did not evaluate sagittal plane deformity of the knee.
twenty-seven joints included were stage 2, twenty-two were stage 3A, and two Values are given as the mean and the standard deviation. Changes in
were stage 3B. According to the Kellgren-Lawrence system for knee osteoar- AOFAS scores, TAS angle, TLS angle, lateral talometatarsal angle, heel align-
11 ment ratio, mechanical ankle joint axis point, and hip-knee-ankle angle were
thritis , twelve knees were grade 0 (no features of osteoarthritis), nine were
analyzed by paired t test, and the difference in postoperative AOFAS scores
grade 1 (a small osteophyte of doubtful importance), and six were grade 2
between the opening-wedge osteotomy group and the focal dome osteotomy
(a denite osteophyte but an unimpaired joint space). We did not perform
group was analyzed by two-tailed t test. The difference in postoperative im-
computed tomography for these patients to determine whether rotational de-
provement (the mean difference between the preoperative and postoperative
formity of the tibia was present. No patient had a history of knee injury, knee
AOFAS scores) between the group in which the preoperative points were 0%
instability, or tibial fracture.
and the group in which the preoperative points were >0% was analyzed with the
A medial opening-wedge tibial osteotomy (twelve ankles) or focal dome
unpaired t test. The difference in postoperative improvement between groups
valgus osteotomy (fteen ankles), each with a bular osteotomy at the same
classied by the postoperative mechanical ankle joint axis point was analyzed
level, was performed. The degree of correction was assessed on the basis of the
using the Wilcoxon rank-sum test with Bonferroni correction. Correlations
intraoperative radiograph, aiming for a TAS angle of 98 and a tibial-lateral
between the preoperative mechanical ankle joint axis point and the postoper-
surface (TLS) angle (the angle between the axis of the tibia and a line drawn
ative mechanical ankle joint axis point, between the preoperative heel align-
between the anterior and posterior margins of the tibial plafond) of 82, as
8 ment ratio and the preoperative mechanical ankle joint axis point, and between
recommended by Tanaka et al. . A locking plate (opening-wedge osteotomy) or
the preoperative heel alignment ratio and the postoperative AOFAS score were
an external xator (focal dome osteotomy) was used for tibial xation. The
assessed with the Pearson correlation coefcient. The level of signicance was
osteotomy gap in the opening-wedge osteotomy was lled with b-tricalcium
set at p < 0.05.
phosphate. We performed percutaneous Achilles tendon lengthening by triple
hemisection in four patients with gastrocnemius contracture. For patients with
a thin body habitus, we performed focal dome osteotomy with an external Source of Funding
xator to avoid skin problems. No external funding was obtained for this study.
Follow-up evaluation was done at three weeks, three months, six
months, one year, and two years. Clinical assessment was performed at the time Results
of nal follow-up with use of the American Orthopaedic Foot & Ankle Society Part I. Reliability of Identifying the Mechanical Ankle Joint
12
(AOFAS) scale . Dorsiexion and plantar exion angles were measured. Axis Point on Hip-to-Calcaneus Radiographs
Hindfoot motion (inversion and eversion) outcomes were assessed according to
12
the AOFAS hindfoot scoring guidelines . For patients with a normal, contra-
lateral ankle, we used hindfoot inversion and eversion on that side as the
I ntraclass correlation coefcients for intraobserver agreement
with regard to mechanical ankle joint axis point measure-
ments are summarized in Table I. The interobserver correlation
standard. For the other patients, we used 40 as the standard value, as described
previously .
13
coefcient for mechanical ankle joint axis point measurements
Radiographic assessment was based on weight-bearing anteroposterior was 0.9922 (95% CI, 0.9915 to 0.9928).
and lateral ankle radiographs as well as the hip-to-calcaneus radiograph. The
TAS angle was measured on the weight-bearing anteroposterior radiograph. Part II. Weight-Bearing-Line Analysis in Relation to Clinical
The tibial axis was dened as the line between the midpoints of the tibial shaft
8 Outcomes
8 cm and 13 cm proximal to the tip of the medial malleolus . We also measured
the TLS angle and the lateral talometatarsal angle (the angle between the talar
The mean AOFAS score improved signicantly from 44.4 16.91
head and axis of the neck and the rst metatarsal axis) on the standing lateral points (range, 13 to 75 points) preoperatively to 86.8 15.24
radiograph. We did not routinely make weight-bearing anteroposterior radio- points (range, 44 to 100 points) postoperatively (p < 0.001). There
graphs of the foot. We determined the mechanical ankle joint axis point on the was no signicant difference between the postoperative AOFAS
hip-to-calcaneus radiographs preoperatively and at the time of the nal follow- score for the focal dome osteotomy group and that for the
up. To evaluate local hindfoot alignment, we calculated the heel alignment ratio
14
opening-wedge osteotomy group (p = 0.90). The mean preop-
described by Lee et al. . The heel alignment ratio was originally calculated by
erative dorsiexion was 9.3 (range, 15 to 35) and plantar
dividing the width of the calcaneus medial to the axis of the tibia by the greatest
width of the calcaneus on the hindfoot alignment radiograph. We measured the
exion was 44.6 (range, 25 to 65), and the mean postoperative
ratio using the lower part of the hip-to-calcaneus radiographs in our patient angles were 9.6 (range, 0 to 30) and 49.8 (range, 25 to 70),
series. A larger positive heel alignment ratio indicates a greater medial, or varus, respectively. Three ankles had moderately restricted hindfoot
deviation of the calcaneus. We also measured the hip-knee-ankle angle, dened motion both preoperatively and postoperatively. The other
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Fig. 2
Distribution of the preoperative mechanical ankle
joint axis points and the postoperative mechanical
ankle joint axis points of each ankle. A total of
eleven ankles had a preoperative mechanical
ankle joint axis point of 0% (preoperative points
for these ankles are indicated by red diamonds).
These points did move somewhat laterally with
surgery, but many of these points did not reach
60% of the ankle joint (postoperative points for
these ankles are indicated by red diamonds).

twenty-four ankles had normal or mildly restricted motion both axis point correlated with the postoperative mechanical ankle
preoperatively and postoperatively. joint axis point (r = 0.59, p = 0.001). Negative correlation
The mean values for radiographic parameters are sum- was found between the preoperative heel alignment ratio and
marized in Table II. The preoperative mechanical ankle joint the preoperative mechanical ankle joint axis point (r = 20.76,

Figs. 3-A, 3-B, and 3-C Radiographs of a fty-four-year-old

woman with varus-type osteoarthritis of the ankle. Fig. 3-A
Preoperative hip-to-calcaneus radiograph showing oblitera-
tion of the joint space between the medial malleolus and the
medial facet of the talus with subchondral bone contact and
the mechanical axis (red line) passing through the medial
part of the ankle joint. Fig. 3-B Hip-to-calcaneus radiograph
made three years after supramalleolar osteotomy. Fig. 3-C
The lower part of the postoperative hip-to-calcaneus radio-
graph shows that the mechanical axis (red line) has been
transferred to the lateral part of the ankle, and the joint
space between the medial malleolus and the medial facet of
the talus has opened.

Fig. 3-A Fig. 3-B Fig. 3-C

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TABLE II Preoperative and Postoperative Radiographic Findings
Preop. Values (N = 27)*
Tibial-ankle surface angle (deg) 85.0 3.51 (78 to 91)
Tibial-lateral surface angle (deg) 80.5 3.11 (72 to 85)
Lateral talometatarsal angle (deg) 12.6 10.2 (29 to 28)
Heel alignment ratio 0.54 0.23 (0 to 0.91)
Mechanical ankle joint axis point (%) 15.9 25.21 (223 to 60)
Hip-knee-ankle angle (deg) 1.8 3.05 (23.9 to 8.6)
*Values are given as the mean and standard deviation, with the range in parentheses. Paired t test.
p < 0.001). On average, the mechanical ankle joint axis points
were moved to the lateral side of the ankle joint postopera-
tively; the mean preoperative mechanical ankle joint axis point
was 15.9% 25.21% (range, 223% to 60%), and the mean
postoperative mechanical ankle joint axis point was 69.5%
24.07% (range, 13% to 113%). However, the locations of the
postoperative points varied greatly (Fig. 2), despite the mean
postoperative TAS angles being similar as well as close to our
target angle. A total of eleven ankles had a preoperative me-
chanical ankle joint axis point of 0%. The points in this group
moved somewhat laterally with surgery, but many points did
not move sufciently to the lateral side of the ankle joint
Fig. 4
Bar graph showing the postoperative improvement in scores for the three
groups based on the postoperative mechanical ankle joint axis point (<60%
for nine ankles, 60% to 79% for eight, and 80% for nine). The top and
bottom of each box represent the 75th and 25th percentiles, the horizontal
line inside the box represents the median, the diamond represents the
mean, and the whiskers are the minimum and maximum values. There was
signicantly greater improvement in the ankles with a postoperative me-
chanical ankle joint axis point of 80% than in the ankles with a postop-
erative mechanical ankle joint axis point of <60% (p = 0.030; Wilcoxon
rank-sum test with Bonferroni correction). The asterisk indicates a sig-
nicant difference.
W E I G H T - B E A R I N G -L I N E A N A LY S I S I N S U P R A M A L L E O L A R O S T E O T O M Y
F O R VA R U S -T Y P E A N K L E O S T E O A R T H R I T I S
Postop. Values (N = 27)* P Value
98.3 4.31 (89 to 105) <0.001
82.3 4.22 (73 to 94) 0.03
13.9 9.7 (218 to 29) 0.48
0.018 9.4 (20.44 to 0.64) <0.001
69.5 24.07 (13 to 113) <0.001
2.2 3.14 (25.4 to 8.5) 0.21
(Fig. 2); the mean postoperative mechanical axis point was 50%
(range, 13% to 70%) in these ankles, whereas the mean post-
operative point was 81% (range, 48% to 113%) in ankles for
which preoperative points were >0%. The mean postoperative
improvement (the mean difference between the preoperative
and postoperative AOFAS scores) in the group in which the
preoperative points were 0% was signicantly lower than that
in the group in which the preoperative points were >0% (30.5
17.31 points versus 50.6 12.84 points; p = 0.004). Examples of
a patient from each group are shown in Figures 3-A, 3-B, and
3-C and in a gure in the Appendix. There was negative corre-
lation between the preoperative heel alignment ratio and the
postoperative AOFAS score (r = 20.50, p = 0.008).
The twenty-seven ankles were divided into three groups
on the basis of the postoperative mechanical ankle joint axis
point (<60% for ten ankles; 60% to 79% for eight; and 80% for
nine). The mean postoperative AOFAS score improvement in
each group was 29.9 17.6 points, 47.3 11.6 points, and 52.1
14.8 points, respectively. Signicantly greater improvement was
seen for ankles with a postoperative mechanical ankle joint axis
point of 80% than for ankles with a postoperative mechanical
ankle joint axis point of <60% (p = 0.030) (Fig. 4).
Discussion
S upramalleolar osteotomy is being used increasingly for the
treatment of mid-stage ankle osteoarthritis1-10. Although
weight-bearing-line analysis would help in operative planning
and postoperative assessment, it has been difcult to determine
this line in the ankle. We developed the hip-to-calcaneus ra-
diograph with high reliability for assessing the mechanical axis
point at the ankle. We showed that tibial correction based solely
on the TAS angle leads to wide variation in the locations of the
postoperative mechanical ankle joint axis point. In patients
with a preoperative point more medial than the tibial plafond,
the point was insufciently moved to the lateral side and the
clinical outcomes were less satisfactory.
The mechanical axis of the lower limb determined from a
full-length standing anteroposterior radiograph has been tra-
ditionally dened as a line from the center of the femoral head
to the center of the tibial plafond and is a key indicator of
malalignment and deformity from the hip to the lowest part of
the tibia15. However, little attention has been paid to where the
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mechanical axis of the lower limb passes through the ankle, and
hindfoot alignment has been evaluated only in relation to the
distal axis of the tibia16. Because of the various foot and ankle
disorders with hindfoot malalignment, we consider evaluating
the mechanical axis at the ankle to be crucial for preoperative
planning and postoperative evaluation in patients having
hindfoot reconstructive surgery.
For our radiographic method, rotation of the lower
limb is critical to the position of the heel contact point, which
affects the position of the mechanical ankle joint axis point.
We use the patella, rather than the foot or ankle, as a guide for
controlling limb rotation. The axis of the foot is traditionally
used to control rotation of the limb in making radiographs for
hindfoot evaluation, with the foot placed with its axis parallel
to the x-ray beam; however, the foot axis is often abnormally
deviated in patients with foot and ankle malalignment. If the
transmalleolar axis is used to control limb rotation, by posi-
tioning the ankle so that the transmalleolar axis is perpen-
dicular to the x-ray beam, the lower limb is rotated internally
because the transmalleolar axis is rotated externally in relation
to the transepicondylar axis of the femur. A cadaver study17
showed that the knee-forward position was within 5 of true
accuracy when the patella was used as a guide to neutral ro-
tation. Thus, we believe that if there is no patellar malposition
or tibial deformity, using the patella to control the limb ro-
tation is reasonable.
Supramalleolar tibial osteotomy is generally a reliable pro-
cedure for the treatment of asymmetric ankle osteoarthritis1-10.
Tanaka et al. assessed the results of low tibial valgus osteotomy
for varus-type osteoarthritis of the ankle8. They performed
opening-wedge osteotomy in twenty-six ankles. In the ankles
that were classied radiographically as stage 2 or stage 3A,
the joint space was restored, whereas only two of twelve ankles
classied as stage 3B had such restoration. Tanaka et al.
concluded that low tibial osteotomy is indicated for stage-2
or stage-3A ankle osteoarthritis. Lee et al. performed
supramalleolar tibial osteotomy to treat moderate medial
ankle osteoarthritis in sixteen ankles5. The mean AOFAS score
was higher for patients with low postoperative talar tilt than for
patients with high talar tilt, and the authors concluded that
supramalleolar osteotomy is indicated for ankle osteoarthritis
in patients with minimal talar tilt. Pagenstert et al. found the
postoperative osteoarthritis stage and talar tilt angle to be
correlated with the postoperative AOFAS score after realign-
ment surgery for asymmetric ankle osteoarthritis9, whereas
the preoperative osteoarthritis stage and TAS angle did not
correlate with the postoperative score. Most of the joints in-
cluded in the present study were at stage 3A. Only three joints
were at stage 2, and only two joints were at stage 3B. Although
it is difcult to statistically analyze the clinical outcomes on the
basis of the preoperative osteoarthritis stage because of the
small number of ankles at stages 2 and 3B, we believed that
the osteoarthritis stage would adequately reect neither the
weight-bearing line at the ankle joint nor the clinical outcomes.
We showed that locations of the postoperative weight-bearing
point varied greatly despite the similarity of the mean post-
W E I G H T - B E A R I N G -L I N E A N A LY S I S I N S U P R A M A L L E O L A R O S T E O T O M Y
F O R VA R U S -T Y P E A N K L E O S T E O A R T H R I T I S
operative TAS angle to angles reported previously 5,8, which
suggests that the TAS angle is not reliable for determining the
correction angle of the tibia.
Several factors contribute to the excessively medial po-
sitioning of the mechanical ankle joint axis point in the ankles
with varus-type osteoarthritis. In light of this, we continue to
use a corrected TAS angle of 98 as our supramalleolar oste-
otomy target, but we now perform additional procedures in
some patients, with the goal of moving the mechanical axis
more laterally. For instance, we may perform a lateral sliding
calcaneal osteotomy and/or opening-wedge medial malleolar
osteotomy, combined with a supramalleolar osteotomy with a
possible target TAS angle of a little more than 98. It may also
be benecial to add a lateral ligament reconstruction and/or
deep deltoid ligament release. However, the long-term results
obtained by adding these procedures remain undetermined.
Most of the patients had some lateral instability; how-
ever, as in previous reports5,8, we did not reconstruct the lateral
ligament. Some patients would have had some rotational in-
stability as well, and that could be one of the reasons for re-
sistance to single-level correction.
For asymmetric ankle osteoarthritis, the function of the
subtalar joint is important. Hayashi et al. showed that the heel
in many stage-3A ankles was in a valgus position because of the
compensatory function of the subtalar joint18. Lee et al. showed
that heel alignment ratio of stage-3B and stage-4 ankles was
signicantly larger than that of normal ankles, whereas that of
stage-2 and stage-3A ankles did not differ signicantly from
that of normal ankles14. The preoperative heel alignment ratios
in our series showed that the heel alignment varied, and the
greater the preoperative varus alignment of the heel, the worse
the clinical outcome.
It is difcult to predict the postoperative alignment of the
subtalar joint and its compensatory function preoperatively.
Thus, an accurate correction angle cannot yet be decided before
supramalleolar osteotomy by the radiographic method. One of
the goals of our study was to correlate the mechanical ankle
joint axis points to the clinical results of the osteotomy and nd
a predictor of a poor outcome from the mechanical axis
standpoint. The ultimate goal should be to decide the correc-
tion angle preoperatively or during surgery using the me-
chanical ankle joint axis point.
In conclusion, traditional tibial correction based on the
TAS angle leads to high variation in the locations of the post-
operative mechanical ankle joint axis point, which suggests that
the TAS angle is not a reliable index for determining the cor-
rection angle of the tibia. In the ankles with preoperative points
more medial than the tibial plafond, the point was insuf-
ciently moved to the lateral side, and the clinical outcomes were
less satisfactory. Modication of the procedure to shift the
mechanical axis more laterally is required for these ankles.
Appendix
Figures showing radiographs of an eighty-two-year-old
woman with knee and ankle osteoarthritis and a sixty-six-
year-old woman with varus-type osteoarthritis of the ankle are
 339
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O L U M E 97-A N U M B E R 4 F E B R UA R Y 18, 2 015
d d
available with the online version of this article as a data sup-
plement at jbjs.org. n
Naoki Haraguchi, MD
Koki Ota, MD
Naoya Tsunoda, MD
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Tokyo Metropolitan Police Hospital,
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