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Chapter 66 Supramalleolar Osteotomy with Internal Fixation: Perspective 2

T E C H N I Q U E S

inaccurately may lead to relative translation of the distal and proximal fragments, resulting in malalignment of the ankle joint under the tibial shaft axis. ■ We recommend using a wide saw blade to create a congruent osteotomy ( TECH FIG 7C,D ). ■ Alternatively, a chisel or osteotome may be used instead of the oscillating saw to limit thermal injury to bone. ■ The correction is based on preoperative planning. ■ The gap can be filled with allograft (we use Tutoplast Spongiosa, Tutogen Medical GmbH, Neunkirchen, Germany) or autograft iliac crest bone ( TECH FIG 7E ).

■ We typically secure the osteotomy with a medial locking plate, but plates with an integrated spacer (eg, Puddu plate, Arthrex Inc., Naples, FL) can be used instead ( TECH FIG 7F ). ■ Fixation of the osteotomy is as described earlier in the section entitled Lateral Closing Wedge Osteotomy to Correct Valgus. ■ The tendon sheath of the posterior tibial tendon is reapproxi- mated with 2-0 absorbable sutures and the subcutaneous tis- sues and the skin are closed with interrupted sutures. Do not overtighten the posterior tibial tendon sheath because it may create stenosing flexor tenosynovitis. ■ Case results are shown in TECH FIG 8 .

TECH FIG 8 ● Pre- and postoperative radiographs (weight-bearing anteroposterior, lateral, and Saltzman views, respectively) of a 62-year-old male patient with varus os- teoarthritis of his ankle joint. The postoperative images are made 1 year after a medial opening wedge osteotomy.

■ Medial Closing Wedge Osteotomy for Correcting Valgus Malalignment ■ The technique essentially is the same as for the opening wedge osteotomy described in the previous section with removal of a bone wedge.

■ K-wire placement is done according to the planned correction ( TECH FIG 9A ). ■ The bone wedge is then removed ( TECH FIG 9B ) and the cor- rection secured with a medial plate. ■ A clinical example is shown in TECH FIG 10 .

TECH FIG 9 ● A. K-wire placement for a medial closing wedge osteotomy. B. Wedge removal in a medial closing osteotomy. A B