Description of patient (type of occupation, indication of age, intensity of sport):
52 year old male patient in good health, office worker. Stopped running since years
History and previous treatment:
History of tibia shaft fracture treated conservative. Since 6 and more years he has ankle pain and was treated successfully with HA injections. Injection therapy does not help anymore and there is also knee pain, but less than in the ankle.
Weight bearing pain in the right knee and ankle.
The right ankle has a moderate swelling. There is good stability, range of motion slightly limited. He has no neurological symptoms. The blood supply is good.
[Picture 1 - 5]
X-ray of the right ankle shows a reduction of the joint space and a deformity. The long leg standing x-ray shows a varus deformity in the tibia, lowering of the joint space in the medial compartment of the knee and a varus tilt of the talus. The weight bearing axis runs through the medial compartment of the knee.
Additional investigation (CT/MRI):
[Picture 6 + 7)
MRI of the ankle shows a reduction of cartilage height and loss of cartilage anterior. There is a large osteophyte at the anterior distal tibia and marrow edema as well.
Symptomatic right Varus Knee Osteoarthritis and Ankle Osteoarthritis in a mid-aged 52 year old male patient.
Question(s) to this case:
I think that the patient will benefit from HTO and an ankle arthroscopy. Would you do an additional osteotomy around the ankle or do you think that the HTO alone will be beneficial for both knee and ankle OA. Arthroscopic debridement? Osteotomy around the ankle?
I would do the HTO and calculate the joint position after the HTO. If the ankle joint position is not horizontal yet and still more then 6-7 degrees off then combine with supramalleolair osreotomy. If, less than 6 degrees off then combine with calcaneal slide lateralizing osteotomy. The lateralization should be 5- 7.5 mm.