Hello, this is Mark Easley, and I'm excited to introduce this session, International Experience with Supramalleolar Osteotomies. We have quite a faculty. I'm here to participate, but I'm also here to learn, so I think this will be very exciting. I've got Jacob Zide with me here from the United States, and this is a joint venture with the Korean Foot and Ankle Society joining the American Orthopedic Foot and Ankle Society. So, to make the introductions for the Korean group, I'm going to turn it over to Hongjun Jung. Hello, thank you, Mark Easley. I'm Hongjun Jung from Korea, and it is my great honor and pleasure to be the moderator for this wonderful historical webinar between the Korean Foot and Ankle Society and AOFAS. We have great faculties, and from the Korean side, we have Dr. Woo-Chun Lee and Dr. Jin-Soo Seo. They are both past Korean Foot and Ankle Society presidents and very much experts in this field, and I'm so happy to be moderating with Dr. Mark Easley, who is an old friend of mine. Well, I mean, you may be right about that. We're definitely friends, and the old is right. Now, I'm really old, so I will say this is the exciting part, is that we'll talk about, we'll try to be comprehensive, so we'll talk about the valgus deformity, we'll talk about the varus deformity and how to correct those, and if time permits, we'll also talk about how we may be able to incorporate total ankle replacement and combine that with supramalleolar osteotomy. So, Hongjun, you take over. Yeah, thank you. So, we have quite a limited time, so, well, I recommend keeping the time, and we have three lectures, each 13 minutes. The first one comes, will be started with, by Dr. Seo Jinsoo, about various deformity realignment. So, please, Dr. Seo, start your lecture. Thank you for my introduction. Okay, let's go for the presentation. Okay, can you see this? Yes, it's perfect. Go ahead. Mm-hmm. Okay. Good morning, everyone. I am Jinsoo Seo from South Korea. It's a great honor to give a talk at this LFAS webinar. Today, my topic is the expansion of indication in varus ankle realignment surgery. I have no potential conflicts with this presentation. First of all, I want to briefly review the general concept of supramalleolar osteotomy. Symptomatic ankle arthritis is less than 1% of population, compared to knee osteoarthritis, which is 6% of population. Two-thirds of the ankle arthritis present with an asymmetric wear pattern, which give a chance to need realignment surgery. Post-traumatic arthritis is the most common cause. Low tibial osteotomy is as opposed to high tibial osteotomy, also called as supramalleolar osteotomy. At first, this technique was reported in 1987. Takakura made up the concept of the surgery treating varus-type ankle arthritis after fracture. As you know, Takakura classified the varus ankle osteoarthritis, and his colleague Tanaka modified it. This classification has been used at present. Hinterman performed the surgery to correct varus-type ankle arthritis, and Teramoto reported oblique-shaped osteotomy to treat varus deformity. Woo-Chun Lee reported distal tibial osteotomy without fibula osteotomy to treat varus-type widened mortis deformity, and named it mortisplasty. Supramalleolar osteotomy is normally indicated for malaligned ankle arthritis, malunited distal tibial fracture, or fusion and deformities, and it is mainly indicated for the patients younger than 65 years with early to mid-stage ankle osteoarthritis. End-stage arthritis, severe instability, vascular or neurologic deficiency, neuroarthritis can be absolute contraindications. Older age, osteoporosis, and smoking are the relative contraindications. With standing AP radiographs, TAS angle should be measured and aimed for a slight valgus overcorrection. TLS angle also should be measured with standing lateral ankle radiograph. Haraguchi used a new method involving a full-length standing PA radiograph, so-called hip-to-calcaneus radiograph. If the mechanical axis line point in ankle located medial, then the platform preoperatively, the clinical outcomes were less satisfactory. In other words, you have to evaluate the overall alignment of the lower extremities as well as the ankles. Since Takakura reported a great outcome of low-tibial osteotomy in 1998, many articles have reported good results. However, Tanaka insisted that stage 3b did not show predictable improvement after osteotomy. Later, Woo-Chun Lee found that the problem was not the preoperative stage itself, but the increased preoperative TALA tilt more than 7.3 degrees. A greater TALA tilt resulted in a decreased AFAS score and an increased postoperative stage. To overcome this issue, a very good solution was present. Myerson and his colleagues presented a platform plastic that improved TALA tilt from 18 degrees to 10 degrees. In their study, preoperative TALA tilt in most patients was more than 8 degrees. In addition, Hintemann presented a double osteotomy technique for correction of intra-articular and extra-articular deformity. The TALA tilt improved dramatically from 19 to 7 degrees. They also explained that the joint road axis had moved medially to the center of TALOS after the osteotomy. Thus, the resultant force was converted to an inverter force. Woo-Chun Lee stated that in the case without definite tibial erosion, angulation in the middle of the platform was unnecessary. Moreover, an intra-articular osteotomy with cartilage plastic deformation is technically demanding and an iatrogenic intra-articular fracture might be complicated. This is what we have published in 2020. We tried to correct the severe varus deformity of which the TALA tilt more than 8 degrees. We found that additional infra-malleolar correction such as calcaneal osteotomy and first metatarsal osteotomy was related to greater TALA tilt correction, lateralization of TALA center, and hind foot valgization. As a conclusion, we recommended adding infra-malleolar correction after low tibial osteotomy with more significant varus tilt ankle arthritis. This 53-year-old woman complained repeated sprain and medial ankle pain. Initially, we did the supra-malleolar osteotomy and fibular osteotomy with deltoid ligament release and modified Brostrom procedure. Postoperatively, TALA tilt was improved somewhat, but the hind foot varus was still remained. As her symptoms persisted by postoperative 15 months, we removed hardware and performed infra-malleolar correction, including DUI osteotomy and first metatarsal osteotomy with tibialis posterior tendon lengthening. At one year after the second operation, hind foot was improved and TALA tilt was corrected. This is a recent publication in this study. We compared two different types of tibial osteotomy. Distal syndesmotic osteotomy aimed very close to the joint level for the correction of intra-articular deformity. Simultaneously, the fibular osteotomy whose level was moved distally to the syndesmotic for the shortening and slight valgization of fibula. Compared to the conventional proximal syndesmotic osteotomy, this technique showed greater TALA tilt correction, especially in case with larger TALA tilt. It was also beneficial for the TALA center lateralization and hind foot valgization. These are the examples of what I have talked. A dramatic TALA tilt correction from 8.4 to 1.7 degrees could be achieved in this 63-year-old woman. Also, see another 64-year-old woman with satisfactory radiographic correction. There are many ideas and methods introduced for TALA tilt correction in this study. We also applied the external fixator on the medial side of ankle after the osteotomy for three months. Another study from Japanese group presented the result from distal tibial osteotomy with a ring external fixator application for distraction osteoplasty. In another study, also performed lateral ligament repair with a temporary fixation of a talofibular joint for six weeks after the osteotomy. In my personal view, the patient's inconvenience and the joint penetrating fixation make us reluctant to performing this technique. More recently, Woo-Chun Lee performed the posterior tibial stentum transfer for the correction of a severe TALA tilt. The result showed a dramatic correction of TALA tilt, but they found more than 14 degrees of TALA tilt cannot be corrected with this technique. Furthermore, posterior tibial stentum transfer must not be performed in ankles with flat foot or hind foot valgus. Let's go for the fibula issue. After fibula osteotomy, appropriate fibula position is very important, but in this deformed mortise condition, it is very difficult to position the fibula accurately. In the case of large TALA tilt, the fibula should be a closing wedge osteotomy. Considering the hind foot valgus and TALA center lateralization and reduced TALA crural angle. This is a CADEVA study about the pressure of a talofibular joint after the supramalleolar osteotomy. They concluded that fibula osteotomy was necessary to minimize the pressure in the talofibular joint, especially when the osteotomy gap was large. This is another study about the necessity of fibula osteotomy. They also mentioned that fibula osteotomy was necessary in cases with large TALA tilt. To correct TALA tilt, medial side soft tissue release and lateral ligament repair basically can be done if it is needed. In cases with large TALA tilt, oblique and distal syndesmotic tibial osteotomy is recommended. In my opinion, fibula osteotomy is also recommended to perform at distal syndesmotic level with closing wedge shape for slight valgus and shortening. Inframalleolar correction might be added for greater correction of TALA tilt. In more severe cases, we can consider performing plafondoplasty for the case with medial tibial erosion or posterior tibial tendon transfer in cases without past planar valgus. However, we still need more concrete evidences and data for the other techniques. For the cartilage regeneration, there might be age limitation. Usually, patients under 65 years are a good indication. Recently, Honggeun Jeong reported that medial tibial TALA tilt regeneration was identified after supramalleolar osteotomy without any bone marrow stimulating procedure. I think this means clinical improvement after the osteotomy is mainly biomechanical load shift effect. This is the only study about the age limitation of supramalleolar osteotomy. We found that this osteotomy could be applied for patients over 65 years if patient selection was appropriate. And similar radiographic improvements and maintenance could be obtained during the follow-up period. Okay, in summary, it is well known that supramalleolar osteotomy provides good radiological and clinical outcomes in early and mid-stage varus ankle arthritis. In the case of severe varus, there are many studies to achieve better outcome, focusing on the position and shape of tibia and fibula osteotomy. However, we still need more studies with a longer follow-up. Age limitation was previously a relative contraindication, but the patient selection is more important, and it should be re-evaluated. Thank you for your attention. Jim Soo, that may be the best lecture I've ever heard on supramalleolar osteotomies for varus deformity. Great job. Thank you. I've lectured on that topic before, and I much rather would like to hear you. You teach so much better than I do. That was wonderful. We're going to save some questions. I will definitely have some questions, and I even had in my case presentations for the end, I put a lot of slides in there about the studies and the evidence behind what you talked about, and you put everything in there, so I can take all of that out of my case presentations now. You were very comprehensive. Excellent work. So, we'll turn it over to Jacob Zeid now, who's going to talk about the opposite problem, valgus deformity. So, Jacob, take it away. Okay. Okay. So, I'm Jacob Zeid from Dallas, Texas, going to be talking about supramalleolar osteotomy for the correction of valgus deformity. And this talk will have much less science to it, as everything that's been published on valgus essentially was just covered in the previous lecture. I am a consultant for OrthoFix, and there's one frame in this talk that's an OrthoFix frame. So, you know, it's amazing going back and looking through these papers and seeing the history of supramalleolar osteotomy. These are two Russian papers, and seeing this bottom left design really shows where people started thinking about this and the way that we've sort of evolved over the years to take care of these deformities to, you know, more recently, not even necessarily looking at just pure deformity correction, but just having valgus ankle arthritis in this study by our colleagues who are here with us tonight, showing really amazing results in 13 patients. It always amazes me that this osteotomy can decrease the arthritis grade in these patients. Now, I'm going to be talking more about deformity, you know, big deformity correction rather than arthritis without substantial deformity, but I think this is totally amazing. Most papers for valgus ankle arthritis are review papers and tips and techniques. They're good, they're helpful, but there's not a whole lot of science, and so we sort of have to rely on the papers on Varus to give us an idea about how we should be managing these deformities and indications for deformities. The vast majority of these deformities are going to be post-traumatic or congenital slash developmental type deformities, and, you know, our indications for surgery, like I said, are not well-defined in the literature, and so the goals that we are seeking for our surgery are going to be what inform our indications, and in general, the presence of deformity associated with, you know, a relatively younger age is sort of our main indication, and then also as a stage procedure, oftentimes using the osteotomy as a stage one with stage two planning to do something like a total ankle down the road. In general, you know, the workhorse here is going to be either a dome or a closing wedge for your tibial osteotomy. Not a fan of an opening wedge in an adult. I find that they tend to collapse. You get graft collapse, and you oftentimes lose some of your correction and don't think it's worth the small amount of added length in the setting where you have a little bit of a short limb, and then just talking quickly about fibular osteotomy, you know, typically, you're going to make something like an oblique fibular osteotomy, and you can have a discussion about whether or not the fibular osteotomy actually needs to be fixed and so on and so forth, but different from doing the varus correction, when you do your correction of your valgus, you'll create a convex side on your lateral side, and that contour, that lateral fibula, can create a prominence laterally that can be bothersome to the patients, and so I think putting a plate on that in order to diminish that contour can be helpful. So, go through a couple cases. This is a post-traumatic deformity after a growth arrest in a 15-year-old young woman, just drawing the lines here, quite obvious, so she gets a dome osteotomy, and I tend to freehand these, but here's a nice technique published by Dr. Easley last year to use a plate, sort of like a compass, to plan out your osteotomy, which works very nicely. Let me interrupt you for one second. Go back one slide. I'll be really brief. I want to give credit where credit is due, and there's great honor with our Korean colleagues. Dr. Kim and Dr. Park did this work. They are really extraordinary, so they get the credit, and he insisted that I would be the first author, and I talked a lot to Foot & Ankle International. I felt like that was not right, but they insisted that I be first author, even though it's their expertise and their work, so I just wanted to give the credit there. Sorry to interrupt. No, no problem. So, let's keep moving along. Okay, so, effective good correction on her with a dome. Here's something a little bit more complex. This is a teenager with renal osteodystrophy. You can see he's had previous SCFEs. He's had growth modulation approximately. This is drastic improvement in his knee valgus, and he's got significant valgus at his ankles associated with a painful flat foot deformity, and so for him, we do everything as a single stage. Once again, a dome-type osteotomy for his tibia along with a flexible flat foot reconstruction and get a good correction on him, so this can be a really powerful deformity corrector. Here's one of the bigger studies on valgus deformity correction from the mid-90s in JPO, 55 patients with myelomeningocele, And so their indications were difficult with brace wear and valgus deformity of greater than 10 degrees. And you can see they had about 50 good or excellent results out of 55 patients, which is pretty outstanding. And so this is definitely indicated for patients with congenital or developmental deformities. And here's an example of that. This is a young man, um, about 14, 15 year old, 15 years old at the time, uh, with an undefined, uh, an unknown, um, genetic, uh, uh, abnormality. You can see this sort of wild serpentine fibulas coursing behind his tibias, uh, and these really terrible valgus ankles. And so we took him for a dome very well on the right side, but on the left, uh, he went on to a non-union he collapsed and fell back and lost, uh, his correction of this deformity. So for him, we convert him into a frame revised our osteotomy and got him walking on this in the frame. And we were able to dial in our correction and get nice, uh, alignment here for him. Uh, here is a paper, uh, on valgus and maintenance of deformity correction at 36 months. These patients also had, uh, some clinical outcomes in the study that, uh, were reported that show that they, that they tended to improve after deformity correction. Um, and so definitely effective for post-traumatic, uh, this is a patient, uh, you know, in all honesty, I think that this is, this arthritis was probably too severe to expect anything too great out of an osteotomy, but patient was very young, really didn't want to do anything to the ankle joint itself. And so after a long discussion, we decided we would do this as a stage one type procedure and see how things went. Um, and so did a dome for him. He had this synostosis. I didn't think fixing the fibula was necessary. Uh, but unfortunately he did not unite, uh, and broke the plate and fell back, uh, into valgus. And so I thought I had enough bone distally here to correct him with a nail. Uh, I liked the idea of getting that, uh, uh, of reaming the canal and getting that, that bone graft down the canal, uh, to help with getting this thing to heal, which it did. Uh, and I would say he's doing okay, but certainly his deformity is significantly improved. And then one final case, uh, this is kind of a, one of those unbelievable cases. This is a young woman, uh, who has a small child was involved in a motor vehicle collision in Mexico, uh, where they were going to amputate her leg. Her dad threw her in the car and drove her to Dallas where she was cared for by some of our pediatric orthopedists, uh, and plastic surgeons who were able to save her leg, but, uh, you know, with substantial, uh, skin compromise requiring flaps and graphs and developing this growth arrest and really severe, uh, deformity and, uh, limb length discrepancy. And so for her correction, uh, decided to do this with a frame, uh, which is really nice, uh, for any, you know, supramolecular correction, but certainly these more complex ones with bad skin, where you really want to try and dial in the correction and the ability to include lengthening. So we are doing the jigsaw osseotomy by the way, we're able to do this essentially as a percutaneous surgery. Here's the first stage getting her ankle brought around and out of valgus. Uh, you can see the floral shot there with the ankle corrected. Then we move up and do her, uh, high osseotomy for her lengthening. You can see the regenerate coming in here and after she's been, uh, lengthened, uh, in that frame. And oops. So finally she, this is where she started. This is where she ends up with a nice plantigrade foot. Once again, where she started and where she finishes and, uh, and she's actually quite happy now. Um, so in summary, uh, I think the dome and the closing wedge are going to be your workhorse osseotomies, uh, certainly for your valgus deformity. I think you just want to sort of have in the back of your mind, we, we tend to plate all of these things, but a nail or a frame, uh, can be a good primary surgery, but certainly helpful in a salvage situation. Uh, and you just want to give some thought to your fibular osteotomy, how you're going to perform it, how you're going to fix it and avoiding that lateral, uh, contour. Thanks so much. Well, thank you very much for the excellent lecture on the valgus deformity supramalleolar osteotomy. Variety of cases with a, uh, very different type of a fixation. So I think that many, uh, participants will know that, uh, we can use, uh, also the frames or the even dome osteotomy, the nice technique and, uh, thank you very much. So, but in Korea, uh, well, like in Asia, we have a much more, one, uh, more common valgus deformities and much less valgus deformities, but, uh, as the case you have shown us, I think a lot of cases come from the physio injury, uh, at a young age. Okay. So now we can go on to the third lecture of the, uh, surgical technique of the supramalleolar osteotomy about dome and the open and closed wedge by, will be presented by Dr. Woo-Chun Lee. Uh, please go on with your lecture. Thank you. Can you hear me? Okay. Hello. Can you hear me? Yes, we can hear you. Okay. We can hear you perfectly. Yes, sir. Hello everybody. I'm Woo-Chun Lee from South Korea and it is a great honor for me to be here to talk about various different distal tibial osteotomies. These are my disclosures and nothing to do with, uh, related to this presentation. I agree that eccentric arthritis with large talatitis is difficult to be preserved with real alignment surgery and the effect of SMO may fade in several years. But longevity of the total ankle is still not as good as total knee or hip. So I think supramalleolar osteotomy is modified procedure in selected ankles. This slide shows progression of medial cartilage arthritis to end stage arthritis during a nine year period. This type of arthritis seems to be the best indication of supramalleolar osteotomy and higher instance of this type of arthritis in oriental countries may be the reason why SMO is more popular in Korea. I do perform fibula osteotomy in most cases because I believe load sharing, load shifting can be achieved with simultaneous fibula osteotomy as demonstrated by these by mechanical studies. Before I talk about specific techniques, let's review the basics of each osteotomy. The aim of real alignment surgery is to shift the weight from degenerative side to the less or uninvolved side of the joint. Most foot and ankle surgeons tend to consider the varicose angulation as the purpose of the SMO for varicose ankle arthritis. But the mechanism of load shifting is actually the combined effect of varicose angulation and lateral translation of the tibial platform. So I think the position of the ankle relative to the tibial axis should be carefully assessed when you plan the SMO or assess the post-operative result. Sorry. This actually, on the left side, shows the ideal indication of supramalleolar osteotomy. It shows minimal tailor-teal, medial gut narrowing, and a large portion of the tailor is medially positioned relative to the tibial axis. In post-operative radiograph on the right side, the tibial platform is in slight varicose. The ankle mortis and talus is moved lateral to the tibial axis. There are many surgeons who favor tibial-only osteotomy. But I think tibial-only osteotomy often fails to correct the translation of the talus. Left side x-ray shows medial gut narrowing and medially positioned talus. Right side x-ray shows the distal segment translates medially as the tibial-only osteotomy is spread open. Final radiograph on the right side shows that the talus is further medially located to the tibial axis than before the surgery. So this surgery failed in weight shifting to the lateral side. The lateral cortex in both tibia and fibula osteotomy, the lateral cortex is not completely cut, as it is shown on the left side x-ray. So it is more stable, and bone graft is usually not necessary. In contrast, as shown on the right side, the tibial-only osteotomy needs to be made all the way through the lateral cortex. So it tends to be more unstable, and bone graft is usually necessary. The other difference between them is the location of the hinge point. The hinge point of both tibia and fibula osteotomy is less medial to the lateral cortex of the tibia, and in tibia-only osteotomy, it is on the lateral cortex of the tibia. So a smaller degree of opening can achieve correction in both tibia and fibula osteotomy. This slide shows opposite directional movement of the talus and heel to that of the open-edge osteotomy after medial closing-edge osteotomy. Here the talus and hind foot are medially translated after surgery. Currently known aim of domostotomy is large correction of angulation without translation, but in most cases, I do domostotomy for 3D manual correction of the deformity, considering the forelimb alignment and axial plane deformity. These are two different types of domostotomy. On the left side, the concavity of the dome is easily directed, and the talus is easily medially translated as it is vagus angulated. On the right side x-ray, the dome is concave proximally, and it is used when large lateral translation is necessary. More specific techniques will be reviewed briefly. Left side x-ray shows skin incision for tibial osteotomy. The incision is made along the posterior margin of the tibia and slightly curved anteriorly along the posterior margin of the medial malleolus. In open supramalleolar osteotomy, two pins are inserted in the fibula and the tibia to determine the orientation and level of osteotomy. In tibial side, pins are inserted from slightly with slight oblique proximal medial to distal lateral to make room for distal fixation. In fibula side, pins are inserted from proximal lateral to the distal medial for easier lateral angulation and translation. The aim of open ridge osteotomy is normal to slight valgus overcorrection and lateral translation of the talus. In my surgery, about 4 to 5 millimeters of opening is sufficient. In this case, 4 millimeter opening angulates 7 degrees, 5 millimeter angulates 8.5 degrees, and right side x-ray shows 2.6 degrees of angulation achieves 5 millimeter of lateral translation of the ankle. So, big angulation or trans angulation is not big or opening is not necessary. The aim of medial closed medial osteotomy is exactly opposite to that of the open ridge osteotomy. This osteotomy is a little more difficult than open SMO and more difficult in terms of fine-tuning the amount of correction. Similar to the medial open ridge osteotomy, two pins are inserted in each bone. The direction of fibula osteotomy is the reverse direction to that of the open ridge to facilitate medial translation and various angulation of the ankle. Small ridge or bone, which is usually about 3 millimeters, is removed from the medial side and the osteotomy is closed with the blunt force. This is a patient with a history of injury 15 years ago when he was 13 years. The medial clear space is wide and diastasis is present. The fibula is short and the hip-knee line passes medial aspect of the ankle and heel. Postoperative radiograph after medial closing shows well-aligned ankle and heel and improved high-volume alignments. Now, let's turn to dome osteotomy. I use dome osteotomy for three-dimensional correction with intentional translation. This osteotomy is versatile in direction of correction, varus valgus, medial lateral translation, and axial plane rotation is possible. Currently, distal concave dome is known, but I think reverse dome concavity is often useful. This shows Hintemann technique of dome osteotomy oriented following a circle centered in the ankle joint not to translate the ankle. Similar technique was introduced as you have seen before. I make dome osteotomy with an apex about 25 millimeters proximal to the ankle joint and along a large circle centered lower than the ankle joint line. Here, certain passes just above the tibia fibula syndesmosis. The actual osteotomy line, which is highlighted with red color here, is less curved than green colored conventional dome osteotomies. This slide shows why dome osteotomy is necessary to realign the whole limb alignment. This x-ray shows varus ankle with proximal valgus alignment. The hip-knee line passes medial aspect of the ankle and medial open wedge would further displace the ankle laterally. This photo shows the similar patient fibrocytomy and varus of the ankle, which is a good indication for dome osteotomy. Dome osteotomy can be used to correct the rotational malalignment too. These photographs illustrate an example of external rotation of the ankle mortis on axial plane in addition to the knee valgus and ankle varus. In A, the ankle is externally rotated while the patella is facing forward. B, when the ankle is about 15 degrees of normal external rotation, the patella is facing inward. In this case, only dome osteotomy can correct these complex deformities. A plate is used as a template for location of the osteotomy. After anterior longitudinal incision, tibia is exposed. Then the plate is applied over the tibial surface. Low margin of the plate is 5 millimeters proximal to the joint line. Apex of the osteotomy passes through the second and third hole of the plate, which is about 25 millimeters above the joint line. A slight curved line is drawn in the tibia and overlying skin between the anterior and lateral incision for fibula osteotomy. Then the fibula osteotomy is done first. Complete osteotomy is made along a curved line with a micro-saw. Bone thickness at this location is usually 32-35 millimeters, so I use 1 centimeter wide, 35 centimeter long saw blade. Interoperatively, X-ray shows fibrosangulated medially translated ankle temporarily fixed with two Stammer pins. It is easily corrected with a complete tibia and fibula osteotomy. Longitudinal saw marks are made across the osteotomy line, so the degree of displacement can be assessed by the displacement between the saw marks. Right side photo shows medial translation of the distal segment after correction. This patient has an advanced advanced varus ankle arthritis. Whole limb alignment shows slight knee varus and ankle varus. Right side X-ray shows well-maintained correction after dome osteotomy with medial translation and varus angulation of the tibial platform. This is a 49-year-old male patient showing advanced varus arthritis with slight knee varus. Medial closing osteotomy would aggravate the whole limb alignment into varus, so varus angulation and lateral translation was done by dome osteotomy. This patient showed a good result, but only a small amount of lateral translation is possible with this kind of distally concave dome as seen in this patient. Sometimes we need a lateral translation, large amount of lateral translation is necessary, so reverse dome osteotomy was developed. In this patient, realignment was done aiming at the large amount of lateral translation to align the ankle to the hip knee line. Large amount of lateral translation can be done with proximal concave dome osteotomy. In this patient, the distal segment was varus angulated, laterally translated, and internally rotated on axial plane. Degree of varus angulation was limited to slight overcorrection by sawing out a little bone at the medial aspect of the dome osteotomy. Similar patient with large varus telotilt was improved after reverse dome osteotomy. Preoperatively in this patient, there was dorsiflexion limitation, but dorsiflexion increased after dome osteotomy, and this photo shows limited eversion of the same patient. On the right side, the foot became more flexible after dome osteotomy, probably due to relief of the soft tissue contracture in the medial side and posterior aspect of the ankle joint. In summary, realignment surgery should aim at correction of whole limb alignment. Dome osteotomy can achieve three-dimensional correction, which means medial lateral translation, as well as varus felx in coronal plane and rotation of ankle mortis in axial plane. Even recubatum or procubatum also can be corrected. Thank you very much. That was excellent, Dr. Lee, Woo-Chun. That was really amazing. We're going to start our case discussions now, so I'm going to turn it over to Hongjun who's going to present one of his cases, and we can all participate. Hongjun? Can you see my presentation? Yes, perfectly. Okay, so do you see the whole screen with the presentation? It's perfect. It's your first slide. It's your intro slide. We can see it perfectly. Okay, so I'd like to show the three cases of my experience to share with you. Nothing to disclose. Okay, this is the first case of male, 56-year-old. He came to me with a pain, medial ankle pain, and the alpha scale was 37, quite a lot of pain. And this is by the tachycardia stage 3b, about the medial compartment. And so I had a TSM about 83 degrees, you know, arthritis quite advanced. And I did that oblique osteotomy. So according to Dr. Su, so Dr. Su is a more influencing the smotic osteotomy level. And when I do the opening wedge, I do, contrary to Dr. Lee, I do quite a large kind of opening wedge osteotomy, especially for like advanced with a lot of tilted arthritis. For example, this patient had about 11 millimeter wedge height of opening wedge, so corrected. And this is post-op six years, showing that quite a good follow-up, the minimal pain of VAS1, and TACs was corrected from 81 to 90. So it's about 11 degree correction. So after six years the patient has a minimal pain with good activities. That's a great case. Let's ask a few questions. So Dr. Su, you said that you do, and I love this because whether it's with ankle replacement or without, when I'm trying to correct varus, I do soft tissue balancing too. And you emphasize that. So in a case like this, would you add soft tissue balancing? Would you transfer or weaken the posterior tibial tendon? And would you do anything else for soft tissue balancing? I'm sorry, some noise interfered with my hearing. Yeah, a lot of people say that about my voice, that it's just a bad noise. So we'll try one more time. So you mentioned in your lecture that you, for varus deformity, you emphasized the importance of soft tissue balancing. So maybe transferring the posterior tibial tendon or doing medial releases in addition to the bone correction. Would you do soft tissue releases in an extreme varus case like this? Like this case, I usually do medial deltoid ligament release, but the tendon transfer, I'm not very familiar with that technique. If the patient have no neurologic manifestation, manifestation, such as a very weak everter. So if the patient didn't show any other problems, I just do medial ligament release. And also lateral ligament repair, I don't usually do that kind of technique, if the postoperative correction is good. Right. No, that's great. And then, Woo-Chun, you also mentioned the lateral cortex of the tibia being important. Would you have wanted the lateral cortex to be intact, or is it better to weaken that when you have severe deformity like this with a correction as is shown here? If I do an SMO, I always try to preserve the lateral cortex, and it is correct, not completely separated. But here, in this case, I would like to emphasize that this case resulted in a very good result, but I think this case may mislead us to do joint preservation surgery in this case. In every case, when a patient comes with this X-ray, would you recommend joint preservation surgery? My opinion is different. I think we can recommend a joint preservation surgery when we are confident that we can achieve a good result in at least 85 to 90 percent. So, in this case, I think it is very difficult to achieve that kind of high, successful result. So, in this case, my first recommendation would be ankle arthrodesis, considering his age of 56 years. And here, the Taylor tilt, as I say, is 7.7 degrees preoperatively. The Taylor tilt, absolute amount of Taylor tilt is not so important because as the arthritis progresses and the joint deteriorates more and more, the Taylor tilt decreases. So, it cannot be an absolute indicator of joint preservation surgery. And considering the amount of joint preservation and scalloping in the distal tibial platform, then I would recommend, I do not recommend. I think this patient is very happy, but I do not recommend generally joint preservation surgery in this case. Well, Hongjun is an incredible surgeon. That's why he's able to do incredible things. I'm more brave. Jacob, you want to make some comments? Do you have any thing to add or should we let Hongjun go on to his next case? I think this is totally unbelievable. I think it's a great result. I agree. I wouldn't do any other, without a foot deformity of some kind, I think deltoid release is probably the only soft tissue addition I would do here. For me, actually, I don't do much of the stator release. My experience showed that even lateral ligament reconstruction, I rarely do that because in some, even the lateral ankle instability cases after performing SMO, we don't really need that to be done necessarily after SMO. So, it's quite an interesting product. I think because of the reconstructing of the mortis, tilted mortis, even the lateral ankle instability kind of get automatically addressed. So, yeah, you want to go, we don't have too much time. Do you want to go to your next case? All right, the second look shows soft tissue, you know, the tissue regeneration over the taladong gene of the surface. Now, this is second case, three, Takakura Suiage, showing the left side ankle. And the TSA 380, 2.7 degrees. I did the open wedge, usually I use trichotical allograft, designing for the size of the bone. I usually do about 10 millimeter trichotical wedge height. And recently I've been adding proximal tibia cancellers, autogenous cancellers, bone graft together. And this is a case of three months after surgery. And this is three years after surgery. Squire is quite good. As you can see, I do quite an overcorrection for much of the cases. And I think the good outcomes comes with the overcorrection of the cases. And this is six years after surgery, and Squire is a VAS 1 and a VAS 88 after plant removal. So, the patient is going on without any additional surgery or any osteoplasties. So, patient is quite happy. So, two questions. Do you routinely remove the hardware? And number two, is it important if you use locking screws or non-locking screws? Have you seen any problems? I see that, I think you used a combination. Maybe you had locking screws on one side and non-locking screws on the other. Maybe I didn't see that correctly, but is that a problem to use locking screws or is that not a problem? Okay, the first question, I routinely remove the plates in plant and usually post-op one year or if it's later, two years. One of the reasons, two reasons. One is patients quite feel the discomfort because of hardware-related pain, discomfort. And second is while I remove, I do osteoscopic evaluation of the ankle joint to see how much have been the denuded cartilage surface has been recovered. And about the locking plates, I usually, now I use the locking plate for the media lateral post plates. This is not locking at the time of the before. The reason I use locking is more stable and it doesn't change the configuration of the compression state of the SMR. So I think the locking plate is better than non-locking. Yes, sorry. Yes, Dr. Hsu. My opinion, I don't prefer the locking plate in the case of a block bone graft. So I think that will make it enough fixation and stability. So I just use low profile plate, but locking plate will make it better fixation. Yeah. Jacob, what do you think? Another great result. How long do you guys keep these opening wedges non-weight-bearing post-operatively? For my case, it's six weeks, absolute non-weight-bearing. And after then, the patient to start partial weight-bearing with the medical boots. So about three months, we can approach the full weight-bearing without any aids. I'm very impressed. Anytime I've tried to do an opening wedge for deformity in an adult patient, I feel like every time I've had graft collapse. I wonder if you guys have some tricks about how you avoid graft collapse in these opening wedges in adults. Or if you all just don't have that problem, maybe they heal better in South Korea than they do in America. Better diet. The patient looks a little small. In my case, as I showed in my presentation, I don't separate that much, only four millimeters or five millimeters at most. So I don't usually put any bone graft into the gap. And the lateral cortex is an incomplete osteotomy. So construct is very stable. So I don't allow weight-bearing for six weeks, but I'm now considering shortening the period of non-weight-bearing after supramalleolar osteotomy. So you don't need to think about the resorption of allograft or not, because there is no bone graft at all from the first. So here, to say my technique here is quite different from Dr. Woo-Chun Lee, is that I do usually about 10 millimeter height of wedge height. So I routinely use a tricortical allograft. Also, recently I've been adding always autogenous cancerless bone graft for better healing. Just the allograft, I think it's not good enough for healing. And the plate is also important. It needs to be, I think the locking plate is better and also should be stable enough. And I put the patient for three months in walker boots. First month, I took toe-touch weight-bearing and later two months is partial weight-bearing, about 50% body weight. And I think the healing, like when I put the 10 millimeter height of opening wedge, you need to have a good bony healing. And I think autogenous cancerless bone graft is very necessary for my patients. Yeah, that's great, great, great case and really terrific discussion. I think we have time for one more case. Do you want to show your third case? Yes. Quickly, I will show you, this is the cartilage regeneration for the second, this patient. And the third one is, this is a various deformity, but because of physio injury, like Dr. Jai showed several cases. And this patient has a motor vehicle accident 30 years ago, 37 year old female had a very severe various deformity with arthritis and the patient came in with such a lot of problems. So I usually perform opening wedge, but for this patient, as you can see, the deformity is so severe and very deformed without malleolus and as this is a gross model. Let me stop you one time. Can you go back one slide? I just want to ask the panel before our session is over, do you routinely get mechanical access views? So from the hip to the ankle, do you get those x-rays and use those in your planning for every case or is it not always necessary? Dr. Su, what do you think? Yeah, most, all of my cases, I have routinely checked the pre-operative and post-operative full row extremity scanogram. Yes, I think it is absolutely necessary to assess the whole limb alignments when you correct the deformity. And Jacob, what about you? I don't, I mean, it's case by case for me. One other question for you while we're on that, if you have weight-bearing CT scan available in your clinic, a weight-bearing CAT scan, would you use that and does that help your planning or is that not important as we move forward into newer technology? Dr. Su? Sorry, I don't have, I'm a little behind. I have been using a weight-bearing CT for nine years now and I think it is an absolute for assessment of arthritis. And even sometimes it looks quite normal, but there appears joint space nearing on weight-bearing CT, so I think it is very essential to the assessment of the arthritis. All right, Wuchan, your job is if your institution gets a new weight-bearing CT scanner, then you will at least send the old one to Dr. Su. Jacob, do you use weight-bearing CT? We unfortunately don't have one. I would love to have one. I think it would be invaluable. Yeah, I think it'll be important as we move into, you know, into the new age. We have a one that goes only to the ankle, just above the ankle, but there are newer ones that also can interpret all the way to the hip. So, all right. All right, Hongjun, sorry, go ahead. Thank you for answering the questions. Okay, so this is a pre-op gross water of the patient showing the flap on the medial side. Well, so about, because of the many reasons I did, this is a CT scan. This is not weight-bearing CT, but shows that a lot of arthritis on this side here. 3D CT scans showing deformities. And I did a lateral closing wedge osteotomy to realign. Because of the large deformities, the patient had 30 degrees of what is actually various deformities. I did a lateral closing wedge osteotomy. I don't really often do well often, but this patient has a good indication. And I use the plates, which are locking. And, well, this is not locking anyway. So, realign so that the tibia platform and the ankle platform is plateau, is well aligned here. And so you can see that it's a 16 millimeter wedge has been removed with a lateral closing wedge. Now, three years, the patient didn't complain of ankle pain, and now the implants are removed and doing well. So the patient is a quite young patient. So this is it. This is the end of my cases. That is extraordinary. Another great case. Wow, I've learned a lot. It's a great session. It's fun to collaborate with you in Korea. Why don't we, I think we have two minutes. Why don't each of you tell us what you think is the most important message in the United States? We say the take home message you would want the participants to learn. So, Wu Chun, tell us what would you want the most important thing that the participants need to remember? I think when you see ankle arthritis with large telatib, I think there is a three-dimensional deformity. When there is a small degree of telatib, it is a two-dimensional, so you can correct it with a one-plane correction like a supramalleolar osteotomy, medial closing open, or any type. But when there is a three-dimensional deformity, you have to consider the method to correct the three-dimensional deformity. I think it's still very important, and also the whole limb alignment should be assessed at all times. Jacob, what do you think? I think, you know, a lot of these deformities are really tricky, and they have these arthritic ankles, and you're doing this to sort of prevent having to do a more definitive procedure, to do a total ankle, to do a fusion, whatever. And in some of these really stiff post-traumatic ankles, I think that you've got to really take into account the foot position, and make sure that you're bringing the foot into appropriate alignment. Where you put the ankle is what sets the foot. And I think that, you know, when you're doing it for these, as Dr. Lee was just saying, these sort of one-dimensional deformities, you can sort of, you can over-correct into valgus or over-correct into varus in order to try and offload the plafond. I don't think you can do that with these bad post-traumatic deformities that are really stiff. You don't want to over-correct. I think you want to get it neutral, and I think you want to set the foot where it needs to be. Jin-Soo, what do you think? What's the most important message for the participants? Okay. My proposal is, most important thing is hind foot alignment. So please check the overall low extremity alignment and hind foot alignment, and make a plan. Just use as many as possible if you can use, such as soft tissue release, and the tibial and fibular osteotomy, and the inframarolar osteotomy. Whatever you can use. So anyway, the end result should be hind foot alignment should be corrected. That's the most important thing, I think. Yeah, maybe we didn't emphasize it enough. I know I had some of it in my cases too, but don't forget to obtain the hind foot alignment view, right? The Saltzman hind foot alignment view is very, very important. Hong-Jun, you want to have some closing comments for the participants, for the group? Are we not seeing your cases for this? I don't think so. I don't think we have enough time, and we've seen extraordinary cases. What I might do as I do, I did prepare cases. So if there's an opportunity, I'll try to see if we can tie a group of cases to this series, so that online you could see some of the cases and how I thought through them as an addition, but I think we're out of time. I'm so sorry to hear that. We're longing to see your cases. Well, I loved what I saw. This is amazing. Great work. What is your final comment? What do you want to teach the group? What's your closing comment? Well, I think supramalleolar osteotomy, although it came from high tibia osteotomy, I think it's more important in ankle arthritis because it's more, ankle has a lot of huge deformities, and this SMO is much more important for ankles, and this dramatically can be with good results to joint preservation. And I think there is no really huge, not so much age limit, so you can even do for early 70 patients. So I strongly recommend for many foot surgeons to go on, have more interest in using this excellent surgical option for ankle arthritis. That's what I want to say. Well, it is great. Great closing comments from everybody. I want to say one last thing that I think Jacob will agree. Maybe Jacob knows a lot of Korean, but I know no Korean, and I am so impressed with how well each of you speak English. Really, really extraordinary. You're truly international surgeons. So thank you for your teaching today, and it's been an honor to share this session with you. Thank you so much. Thank you. Thank you so much. Thank you very much. My honor. Awesome.

supramalleolar osteotomies

ankle deformities

three-dimensional nature of deformity

limb alignment

pre-operative imaging

post-operative imaging

open-wedge osteotomies

closed-wedge osteotomies

dome osteotomies

soft tissue balancing