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Archives of Orthopaedic and Trauma Surgery

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25-09-2021 | Varus Malalignment | Orthopaedic Surgery

Correction of ankle varus deformity using patient-specific dome-shaped osteotomy guides designed on weight-bearing CT: a pilot study

Authors: Sebastian Faict, Arne Burssens, Aline Van Oevelen, Liselore Maeckelbergh, Peter Mertens, Kristian Buedts

Published in: Archives of Orthopaedic and Trauma Surgery | Issue 2/2023

Abstract

Background

Dome-shaped supramalleolar osteotomies are a well-established treatment option for correcting ankle deformity. However, the procedure remains technically demanding and is limited by a two-dimensional (2D) radiographic planning of a three-dimensional (3D) deformity. Therefore, we implemented a weight-bearing CT (WBCT) to plan a 3D deformity correction using patient-specific guides.

Methods

A 3D-guided dome-shaped supramalleolar osteotomy was performed to correct ankle varus deformity in a case series of five patients with a mean age of 53.8 years (range 47–58). WBCT images were obtained to generate 3D models, which enabled a deformity correction using patient-specific guides. These technical steps are outlined and associated with a retrospective analysis of the clinical outcome using the EFAS score, Foot and Ankle Outcome Score (FAOS) and visual analog pain scale (VAS). Radiographic assessment was performed using the tibial anterior surface angle (TAS), tibiotalar angle (TTS), talar tilt angle (TTA), hindfoot angle (HA), tibial lateral surface angle (TLS) and tibial rotation angle (TRA).

Results

The mean follow-up was 40.8 months (range 8–65) and all patients showed improvements in the EFAS score, FAOS and VAS (p < 0.05). A 3-month postoperative WBCT confirmed healing of the osteotomy site and radiographic improvement of the TAS, TTS and HA (p < 0.05), but the TTA and TRA did not change significantly (p > 0.05).

Conclusion

Dome-shaped supramalleolar osteotomies using 3D-printed guides designed on WBCT are a valuable option in correcting ankle varus deformity and have the potential to mitigate the technical drawbacks of free-hand osteotomies.

Level of evidence

Level 5 case series.

Barg A, Pagenstert GI, Hügle T, Gloyer M, Wiewiorski M, Henninger HB et al (2013) Ankle osteoarthritis: etiology, diagnostics, and classification. Foot Ankle Clin 18:411–426. https://doi.org/10.1016/j.fcl.2013.06.001CrossRefPubMed

Glazebrook M, Daniels T, Younger A, Foote CJ, Penner M, Wing K et al (2008) Comparison of health-related quality of life between patients with end-stage ankle and hip arthrosis. J Bone Jt Surg Ser A. https://doi.org/10.2106/JBJS.F.01299CrossRef

Daniels T, Thomas R (2008) Etiology and biomechanics of ankle arthritis. Foot Ankle Clin. https://doi.org/10.1016/j.fcl.2008.05.002CrossRefPubMed

Saltzman CL, Salamon ML, Blanchard GM, Huff T, Hayes A, Buckwalter JA et al (2005) Epidemiology of ankle arthritis: report of a consecutive series of 639 patients from a tertiary orthopaedic center. Iowa Orthop J 25:44–46PubMedPubMedCentral

Valderrabano V, Horisberger M, Russell I, Dougall H, Hintermann B (2009) Etiology of ankle osteoarthritis. Clin Orthop Relat Res. https://doi.org/10.1007/s11999-008-0543-6CrossRefPubMed

Barg A, Pagenstert GI, Leumann AG, Müller AM, Henninger HB, Valderrabano V (2012) Treatment of the arthritic valgus ankle. Foot Ankle Clin. https://doi.org/10.1016/j.fcl.2012.08.007CrossRefPubMed

Krähenbühl N, Zwicky L, Bolliger L, Schädelin S, Hintermann B, Knupp M (2017) Mid- to long-term results of supramalleolar osteotomy. Foot Ankle Int 38:124–132. https://doi.org/10.1177/1071100716673416CrossRefPubMed

Krähenbühl N, Akkaya M, Deforth M, Zwicky L, Barg A, Hintermann B (2019) Extraarticular supramalleolar osteotomy in asymmetric varus ankle osteoarthritis. Foot Ankle Int 40:936–947. https://doi.org/10.1177/1071100719845928CrossRefPubMed

Barg A, Pagenstert GI, Horisberger M, Paul J, Gloyer M, Henninger HB et al (2013) Supramalleolar osteotomies for degenerative joint disease of the ankle joint: Indication, technique and results. Int Orthop 37:1683–1695. https://doi.org/10.1007/s00264-013-2030-2CrossRefPubMedPubMedCentral

10.

Pagenstert GI, Hintermann B, Barg A, Leumann A, Valderrabano V (2007) Realignment surgery as alternative treatment of varus and valgus ankle osteoarthritis. Clin Orthop Relat Res. https://doi.org/10.1097/BLO.0b013e318124a462CrossRefPubMed

11.

Knupp M (2017) The use of osteotomies in the treatment of asymmetric ankle joint arthritis. Foot Ankle Int 38:220–229. https://doi.org/10.1177/1071100716679190CrossRefPubMed

12.

Bernasconi A, Cooper L, Lyle S, Patel S, Cullen N, Singh D et al (2020) Intraobserver and interobserver reliability of cone beam weightbearing semi-automatic three-dimensional measurements in symptomatic pes cavovarus. Foot Ankle Surg 26:564–572. https://doi.org/10.1016/j.fas.2019.07.005CrossRefPubMed

13.

Peiffer M, Belvedere C, Clockaerts S, Leenders T, Leardini A, Audenaert E et al (2020) Three-dimensional displacement after a medializing calcaneal osteotomy in relation to the osteotomy angle and hindfoot alignment. Foot Ankle Surg 26:78–84. https://doi.org/10.1016/j.fas.2018.11.015CrossRefPubMed

14.

Dagneaux L, Dufrenot M, Bernasconi A, Bedard NA, de Cesar NC, Lintz F (2020) Three-dimensional biometrics to correlate hindfoot and knee coronal alignments using modern weightbearing imaging. Foot Ankle Int. https://doi.org/10.1177/1071100720938333CrossRefPubMed

15.

de Cesar NC, Bang K, Mansur NS, Garfinkel JH, Bernasconi A, Lintz F et al (2020) Multiplanar semiautomatic assessment of foot and ankle offset in adult acquired flatfoot deformity. Foot Ankle Int 41:839–848. https://doi.org/10.1177/1071100720920274CrossRef

16.

Lintz F, Welck M, Bernasconi A, Thornton J, Cullen NP, Singh D et al (2017) 3D biometrics for hindfoot alignment using weightbearing CT. Foot Ankle Int 38:684–689. https://doi.org/10.1177/1071100717690806CrossRefPubMed

17.

Kvarda P, Heisler L, Krähenbühl N, Steiner CS, Ruiz R, Susdorf R et al (2020) 3D assessment in posttraumatic ankle osteoarthritis. Foot Ankle Int. https://doi.org/10.1177/1071100720961315CrossRefPubMed

18.

Netto CDC, Schon LC, Thawait GK, Da Fonseca LF, Chinanuvathana A, Zbijewski WB et al (2017) Flexible adult acquired flatfoot deformity: comparison between weight-bearing and non-weight-bearing measurements using cone-beam computed tomography. J Bone Jt Surg Am 99:e98. https://doi.org/10.2106/JBJS.16.01366CrossRef

19.

Lintz F, de Netto CC, Barg A, Burssens A, Richter M, Group WBCIS (2018) Weight-bearing cone beam CT scans in the foot and ankle. EFORT Open Rev 3:278. https://doi.org/10.1302/2058-5241.3.170066CrossRefPubMedPubMedCentral

20.

Zhang JZ, Lintz F, Bernasconi A, Zhang S (2019) 3D biometrics for hindfoot alignment using weightbearing computed tomography. Foot Ankle Int 40:720–726. https://doi.org/10.1177/1071100719835492CrossRefPubMed

21.

Kvarda P, Krähenbühl N, Susdorf R, Burssens A, Ruiz R, Barg A et al (2021) High reliability for semiautomated 3D measurements based on weightbearing CT scans. Foot Ankle Int. https://doi.org/10.1177/10711007211034522CrossRefPubMed

22.

Ludlow B, Ivanovic M (2014) Weightbearing CBCT, MDCT, and 2D imaging dosimetry of the foot and ankle. Int J Diagn Imaging 1(2):1–9CrossRef

23.

Knupp M, Stufkens SAS, Bolliger L, Barg A, Hintermann B (2011) Classification and treatment of supramalleolar deformities. Foot Ankle Int. https://doi.org/10.3113/FAI.2011.1023CrossRefPubMed

24.

Cox J, Hewes T (1979) “Normal” talar tilt angle. Clin Orthop Relat Res. https://doi.org/10.1097/00003086-197905000-00008CrossRefPubMed

25.

Hayashi K, Tanaka Y, Kumai T, Sugimoto K, Takakura Y (2008) Correlation of compensatory alignment of the subtalar joint to the progression of primary osteoarthritis of the ankle. Foot Ankle Int 29:400–406. https://doi.org/10.3113/FAI.2008.0400CrossRefPubMed

26.

Richter M, Agren PH, Besse JL, Cöster M, Kofoed H, Maffulli N et al (2018) EFAS score—multilingual development and validation of a patient-reported outcome measure (PROM) by the score committee of the European Foot and Ankle Society (EFAS). Foot Ankle Surg. https://doi.org/10.1016/j.fas.2018.05.004CrossRefPubMed

27.

Roos EM, Brandsson S, Karlsson J (2001) Validation of the foot and ankle outcome score for ankle ligament reconstruction. Foot Ankle Int. https://doi.org/10.1177/107110070102201004CrossRefPubMed

28.

Burssens A, Peeters J, Peiffer M, Marien R, Lenaerts T, Vandeputte G et al (2018) Reliability and correlation analysis of computed methods to convert conventional 2D radiological hindfoot measurements to a 3D setting using weightbearing CT. Int J Comput Assist Radiol Surg 13:1999–2008. https://doi.org/10.1007/s11548-018-1727-5CrossRefPubMed

29.

Carrara C, Belvedere C, Caravaggi P, Durante S, Leardini A (2020) Techniques for 3D foot bone orientation angles in weight-bearing from cone-beam computed tomography. Foot Ankle Surg. https://doi.org/10.1016/j.fas.2020.03.013CrossRefPubMed

30.

Najefi AA, Ghani Y, Goldberg A (2019) Role of rotation in total ankle replacement. Foot Ankle Int 40:1358–1367. https://doi.org/10.1177/1071100719867068CrossRefPubMed

31.

Harrington KD (1979) Degenerative arthritis of the ankle secondary to long-standing lateral ligament instability. J Bone Jt Surg Ser A 61:354–361. https://doi.org/10.2106/00004623-197961030-00006CrossRef

32.

Schweizer A, Fürnstahl P, Nagy L (2013) Three-dimensional correction of distal radius intra-articular malunions using patient-specific drill guides. J Hand Surg Am 38:2339–2347. https://doi.org/10.1016/j.jhsa.2013.09.023CrossRefPubMed

33.

Victor J, Premanathan A (2013) Virtual 3D planning and patient specific surgical guides for osteotomies around the knee: a feasibility and proof-of-concept study. Bone Joint J 95-B:153–158. https://doi.org/10.1302/0301-620X.95B11.32950CrossRefPubMed

34.

Weigelt L, Fürnstahl P, Hirsiger S, Vlachopoulos L, Espinosa N, Wirth SH (2017) Three-dimensional correction of complex ankle deformities with computer-assisted planning and patient-specific surgical guides. J Foot Ankle Surg 56:1158–1164. https://doi.org/10.1053/j.jfas.2017.05.025CrossRefPubMed

35.

Tack P, Victor J, Gemmel P, Annemans L (2016) 3D-printing techniques in a medical setting: a systematic literature review. Biomed Eng Online. https://doi.org/10.1186/s12938-016-0236-4CrossRefPubMedPubMedCentral

36.

Berlet GC, Penner MJ, Lancianese S, Stemniski PM, Obert RM (2014) Total ankle arthroplasty accuracy and reproducibility using preoperative CT scan-derived. Patient-specific guides. Foot Ankle Int 35:665–676. https://doi.org/10.1177/1071100714531232CrossRefPubMed

37.

Dagneaux L, Canovas F (2020) 3D printed patient-specific cutting guide for anterior midfoot tarsectomy. Foot Ankle Int 41:211–215. https://doi.org/10.1177/1071100719882723CrossRefPubMed

38.

Shereff MJ, DiGiovanni L, Bejjani FJ, Hersh A, Kummer F (1990) A comparison of nonweight-bearing and weight-bearing radiographs of the foot. Foot Ankle 10:306–311. https://doi.org/10.1177/107110079001000604CrossRefPubMed

39.

Sripanich J, Weinberg M, Krähenbühl J, Rungprai C, Saltzman C, Barg A (2021) Reliability of measurements assessing the Lisfranc joint using weightbearing computed tomography imaging. Arch Orthop Trauma Surg 141:775–781. https://doi.org/10.1007/S00402-020-03477-5CrossRefPubMed

40.

Richter M, Seidl B, Zech S, Hahn S (2014) PedCAT for 3D-imaging in standing position allows for more accurate bone position (angle) measurement than radiographs or CT. Foot Ankle Surg 20:201–207. https://doi.org/10.1016/j.fas.2014.04.004CrossRefPubMed

41.

Barg A, Bailey T, Richter M, de Cesar NC, Lintz F, Burssens A et al (2018) Weightbearing computed tomography of the foot and ankle: emerging technology topical review. Foot Ankle Int 39:376–386. https://doi.org/10.1177/1071100717740330CrossRefPubMed

42.

Brandenburg LS, Siegel M, Neubauer J, Merz J, Bode G, Kühle J (2021) Measuring standing hindfoot alignment: reliability of different approaches in conventional x-ray and cone-beam CT. Arch Orthop Trauma Surg. https://doi.org/10.1007/S00402-021-03904-1CrossRefPubMedCentralPubMed

43.

Lalevée M, Barbachan Mansur NS, Rojas E, Lee HY, Ahrenholz S, Dibbern LF, de Cesar NC (2021) Prevalence and pattern of lateral impingements in the progressive collapsing foot deformity. Arch Orthop Trauma Surg. https://doi.org/10.1007/S00402-021-04015-7CrossRefPubMedCentralPubMed

44.

Burssens A, Barg A, van Ovost E, Van Oevelen A, Leenders T, Peiffer M et al (2019) The hind- and midfoot alignment computed after a medializing calcaneal osteotomy using a 3D weightbearing CT. Int J Comput Assist Radiol Surg 14:1439–1447. https://doi.org/10.1007/s11548-019-01949-7CrossRefPubMed

45.

de Cesar NN, Schmidt E, Lalevée M, Mansur BNS (2021) Flexor tenodesis procedure in the treatment of lesser toe deformities. Arch Orthop Trauma Surg. https://doi.org/10.1007/S00402-021-03942-9CrossRef

46.

Yan CH, Chiu KY, Ng FY, Chan PK, Fang CX (2015) Comparison between patient-specific instruments and conventional instruments and computer navigation in total knee arthroplasty: a randomized controlled trial. Knee Surg Sport Traumatol Arthrosc 23:3637–3645. https://doi.org/10.1007/s00167-014-3264-2CrossRef

47.

Jones GG, Jaere M, Clarke S, Cobb J (2018) 3D printing and high tibial osteotomy. EFORT Open Rev 3:254–259. https://doi.org/10.1302/2058-5241.3.170075CrossRefPubMedPubMedCentral

48.

Burssens A, Vermue H, Weinberg MW, Van Oevelen A, Lauwagie S, Forward M et al (2020) Three-dimensional correction of fibular hemimelia using computer-assisted planning: technical report and literature review. Acta Orthop Belg 86(3):383–390PubMed

49.

Glazebrook M (2018) A new total ankle arthroplasty implant with promising level-IV results: commentary on an article by Alexej Barg, MD, et al.: “Early clinical and radiographic outcomes of trabecular metal total ankle replacement using a transfibular approach.” J Bone Joint Surg Am 2018(100):e39. https://doi.org/10.2106/JBJS.17.01317CrossRef

50.

Wagner P, Colin F, Hintermann B (2014) Distal tibia dome osteotomy. Tech Foot Ankle Surg 13:103–107. https://doi.org/10.1097/BTF.0000000000000037CrossRef

51.

Audenaert EA, Van Houcke J, Almeida DF, Paelinck L, Peiffer M, Steenackers G et al (2019) Cascaded statistical shape model based segmentation of the full lower limb in CT. Comput Methods Biomech Biomed Eng 22:644–657. https://doi.org/10.1080/10255842.2019.1577828CrossRef

52.

Cabarcas BC, Cvetanovich GL, Espinoza Orías AA, Inoue N, Gowd AK, Bernardoni E et al (2019) Novel 3-dimensionally printed patient-specific guide improves accuracy compared with standard total shoulder arthroplasty guide: a cadaveric study. JSES Open Access 3:83–92. https://doi.org/10.1016/j.jses.2019.04.001CrossRefPubMedPubMedCentral

53.

Burssens ABM, Buedts K, Barg A, Vluggen E, Demey P, Saltzman CL et al (2020) Is lower-limb alignment associated with hindfoot deformity in the coronal plane? A Weightbearing CT Analysis. Clin Orthop Relat Res 478:154–168. https://doi.org/10.1097/CORR.0000000000001067CrossRefPubMed

54.

Burssens A, De Roos D, Barg A, Welck M, Krähenbühl N, Saltzman C, Victor J (2021) Alignment of the hindfoot in total knee arthroplasty: a systematic review of clinical and radiological outcomes. Bone Joint J 103-B:87–97. https://doi.org/10.1302/0301-620X.103B1.BJJ-2020-0143.R1CrossRefPubMed

55.

Thelen P, Delin C, Folinais D, Radier C (2012) Evaluation of a new low-dose biplanar system to assess lower-limb alignment in 3D: a phantom study. Skeletal Radiol 41:1287–1293. https://doi.org/10.1007/s00256-012-1438-xCrossRefPubMed

56.

Segal NA, Nevitt MC, Lynch JA, Niu J, Torner JC, Guermazi A (2015) Diagnostic performance of 3D standing CT imaging for detection of knee osteoarthritis features. Phys Sportsmed 43:213–220. https://doi.org/10.1080/00913847.2015.1074854CrossRefPubMedPubMedCentral

Title: Correction of ankle varus deformity using patient-specific dome-shaped osteotomy guides designed on weight-bearing CT: a pilot study
Authors: Sebastian Faict
Arne Burssens
Aline Van Oevelen
Liselore Maeckelbergh
Peter Mertens
Kristian Buedts
Publication date: 25-09-2021
Publisher: Springer Berlin Heidelberg
Keyword: Varus Malalignment
Published in: Archives of Orthopaedic and Trauma Surgery / Issue 2/2023
Print ISSN: 0936-8051
Electronic ISSN: 1434-3916
DOI: https://doi.org/10.1007/s00402-021-04164-9

At a glance: The STEP trials

Springer Medicine

Correction of ankle varus deformity using patient-specific dome-shaped osteotomy guides designed on weight-bearing CT: a pilot study

Abstract

Background

Methods

Results

Conclusion

Level of evidence

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Level of evidence

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