What are the most common complications after supramalleolar (above the ankle) osteotomy (surgical cutting and realignment of bone)?

Most Common Complications After Supramalleolar Osteotomy

The most common complications after supramalleolar osteotomy include bone fracture, inadequate correction, loss of correction, and wound healing problems. While supramalleolar osteotomy is an effective procedure for correcting extra-articular deformities of the distal tibia, understanding potential complications is essential for proper patient management.

Major Complications

Bone-Related Complications

• Complete fracture of the bony segment during the procedure, particularly when attempting to correct more than 6 mm of augmentation 1
• Nonunion at the osteotomy site, which may lead to poor outcomes and require revision surgery 2
• Loss of correction/reduction after initial successful alignment, which can worsen symptoms rather than improve them 3

Wound and Soft Tissue Complications

• Wound breakdown and delayed healing, particularly in patients with compromised vascularity 3
• Surgical site infections, which may present as pin tract infections when external fixation is used 3
• Pain and paresthesia due to potential nerve irritation during the surgical approach 1

Technical Complications

• Failure to completely correct the deformity due to inadequate preoperative planning or technical execution 3, 4
• Compromised implant position when the corticotomy constrains optimal placement 1
• Lack of primary stability at the osteotomy site, which can contribute to nonunion or malunion 1

Risk Factors for Complications

• Attempting corrections greater than 6 mm in a single procedure increases complication risk 1
• Inadequate preoperative planning, which is essential to optimize functional outcomes 4
• Poor bone quality, particularly in patients with underlying metabolic bone disorders 5
• Use of external fixation, which carries risks of pin tract infections 3

Prevention Strategies

• Thorough preoperative planning using appropriate imaging to identify the center of rotation and angulation (CORA) 4
• Careful surgical technique with appropriate cut guides (K-wires) to ensure precise osteotomy 4
• Consideration of 3D imaging and patient-specific instrumentation for complex cases 4
• Appropriate fixation method selection based on bone quality and correction requirements 5

Management of Specific Complications

For Nonunion

• Revision surgery with bone grafting and stable fixation 2
• Assessment of potential contributing factors such as infection or hardware failure 3

For Wound Complications

• Early recognition and aggressive management of surgical site infections 3
• Appropriate soft tissue handling during the initial procedure 6

For Loss of Correction

• Close radiographic monitoring during the healing phase 3
• Consideration of revision surgery if significant loss of correction occurs 2

Long-Term Outcomes

Despite these potential complications, supramalleolar osteotomy has been shown to yield excellent results when performed with appropriate patient selection and proper technique. The procedure effectively redistributes forces more evenly across the ankle joint by restoring the mechanical axis of the lower leg 5.

In a study of patients with tibial malunion, seven out of eight patients reported symptomatic improvement following supramalleolar osteotomy, with the one patient who experienced loss of reduction becoming more symptomatic 3.