Proximal fibular osteotomy in conjunction with supramalleolar osteotomy in concurrent management of ankle and knee osteoarthritis: A case series

Abstract

Management of ankle osteoarthritis (OA) remains a challenge due to its profound impact on pain, function, and quality of life. Supramalleolar osteotomy (SMO) is a joint-preserving procedure that addresses malalignment and redistributes joint loads, while proximal fibular osteotomy (PFO) targets varus deformities and lateral instability. This study explores the outcomes of combining SMO and PFO to treat concurrent ipsilateral ankle and knee OA, providing a comprehensive approach to lower limb pathology.

We report two cases of patients with symptomatic ankle and knee OA managed using a combined surgical strategy. Both patients underwent preoperative clinical evaluations, radiographic assessments, and standardized rehabilitation protocols postoperatively. Surgical procedures included ankle arthroscopic debridement, microfracture, SMO, PFO, and lateral ligament reconstruction as required.

Postoperative outcomes demonstrated improvements in alignment, pain, and function. Patient-reported outcome measures showed marked improvements 6 months postoperatively, with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scores increasing from 40 to 67 in one patient and from 69 to 94 in the other. Pain scores on the visual analog scale (VAS) showed substantial reductions in both cases, and quality of life domains assessed via the RAND 36-item health survey (RAND 36) questionnaire, including physical function and vitality, demonstrated marked gains. Radiographic analysis confirmed effective realignment and increased joint space, with improvements in key angles such as the tibial anterior surface (TAS) angle and talar tilt (TT).

These cases highlight the synergistic effect of SMO and PFO in managing complex ipsilateral lower limb OA. Radiographic and patient-reported outcomes demonstrated improved alignment, pain relief, and functionality. SMO addressed varus malalignment in the ankle, while PFO facilitated medial opening and enhanced correction of TT. Additionally, combining these techniques reduced mechanical stress on the medial knee compartment.

This dual approach shows some promise as a joint-preserving alternative for patients with moderate to severe ipsilateral ankle and knee OA. However, meticulous preoperative planning and patient selection remain essential to optimize outcomes. Further studies with larger cohorts and long-term follow-up are needed to validate these findings and refine surgical indications.

Level of evidence

Level V, Case report.