B. Hintermann

Knee-to-Ankle Mosaicplasty for the Treatment of Osteochondral Lesions of the Ankle Joint

BACKGROUND Osteochondral lesions are frequently seen in athletes after ankle injuries. At this time, osteochondral autologous transplantation (OATS, mosaicplasty) is the only surgical treatment that replaces the entire osteochondral unit in symptomatic lesions. PURPOSE To evaluate the clinical and radiological midterm to long-term outcome of ankles treated with knee-to-ankle mosaicplasty. STUDY DESIGN Case series; Level of evidence, 4. METHODS Clinical evaluation consisted of patient satisfaction, pain evaluation (visual analog scale [VAS]), American Orthopaedic Foot and Ankle Society (AOFAS) ankle score, sports activity score, range of motion, the radiological evaluation of magnetic resonance imaging (MRI), and single photon emission computed tomography-computed tomography (SPECT-CT) analysis of both the ankle and the knee joint. RESULTS Twelve of 21 patients (mean age, 43 years; male, 8; female, 4) were available for latest follow-up (mean, 72 months). At follow-up, patients reported a satisfaction rate of good to excellent in 92% (n = 11) and poor in 8% (n = 1). The average VAS pain score was 3.9 (preoperative, 5.9; P = .02), AOFAS ankle score significantly increased from 45.9 to 80.2 points (P < .0001), sports activity score remained significantly decreased with 1.25 (preinjury level, 2.3; P = .035), and ankle dorsiflexion was significantly reduced (P = .003). Knee pain was reported in 6 patients (50%). Radiologically, recurrent lesions were found in 10 of 10 cases (100%) and some degree of cartilage degeneration and discontinuity of the subchondral bone plate in 100%. CONCLUSION Indications for mosaicplasty with a plug transfer from the knee to the talus must be considered carefully, as at midterm, moderate outcome and considerable donor-site morbidity may be found.Background Osteochondral lesions are frequently seen in athletes after ankle injuries. At this time, osteochondral autologous transplantation (OATS, mosaicplasty) is the only surgical treatment that replaces the entire osteochondral unit in symptomatic lesions. Purpose To evaluate the clinical and radiological midterm to long-term outcome of ankles treated with knee-to-ankle mosaicplasty. Study Design Case series; Level of evidence, 4. Methods Clinical evaluation consisted of patient satisfaction, pain evaluation (visual analog scale [VAS]), American Orthopaedic Foot and Ankle Society (AOFAS) ankle score, sports activity score, range of motion, the radiological evaluation of magnetic resonance imaging (MRI), and single photon emission computed tomography–computed tomography (SPECT-CT) analysis of both the ankle and the knee joint. Results Twelve of 21 patients (mean age, 43 years; male, 8; female, 4) were available for latest follow-up (mean, 72 months). At follow-up, patients reported a satisfaction rate of good to excellent in 92% (n 5 11) and poor in 8% (n 5 1). The average VAS pain score was 3.9 (preoperative, 5.9; P 5 .02), AOFAS ankle score significantly increased from 45.9 to 80.2 points (P< .0001), sports activity score remained significantly decreased with 1.25 (preinjury level, 2.3; P 5 .035), and ankle dorsiflexion was significantly reduced (P 5 .003). Knee pain was reported in 6 patients (50%). Radiologically, recurrent lesions were found in 10 of 10 cases (100%) and some degree of cartilage degeneration and discontinuity of the subchondral bone plate in 100%. Conclusion Indications for mosaicplasty with a plug transfer from the knee to the talus must be considered carefully, as at midterm, moderate outcome and considerable donor-site morbidity may be found.

Sports and Recreation Activity of Ankle Arthritis Patients Before and After Total Ankle Replacement

Background Total ankle replacement is a possible treatment for ankle arthritis; however, participation in sports after this procedure has not yet been analyzed. Hypotheses There is a significant increase of sports activity after total ankle replacement in patients with arthritis. There is a significant correlation between sports activity and American Orthopaedic Foot and Ankle Society hindfoot score in patients after total ankle replacement. Study Design Case series; Level of evidence, 4. Methods A clinical evaluation was performed preoperatively and at follow-up after total ankle replacement in 147 patients (152 ankles) with ankle arthritis (mean age, 59.6 years; range, 28-86 years). Ankle arthritis origin, patient satisfaction, range of motion, American Orthopaedic Foot and Ankle Society hindfoot score, radiologic assessment, and rate, level, and type of sports activity were documented at both evaluations. The mean follow-up was 2.8 years (range, 2-4 years). Results Preoperative diagnosis was posttraumatic osteoarthritis in 115 cases (76%). At total ankle replacement follow-up, excellent and good outcomes were reported in 126 cases (83%); 105 cases (69%) were pain free. The mean range of motion preoperatively was 21° (range, 0°-45°); after total ankle replacement, it was 35° (range, 10°-55°; P < .05). The preoperative American Orthopaedic Foot and Ankle Society score was 36 points; after total ankle replacement, it was 84 points (P < .001). Before surgery, 36% of the patients were active in sports; after surgery, this percentage rose to 56% (P < .001). After total ankle replacement, sports-active patients showed a significantly higher hindfoot score than did patients not active in sports: 88 versus 79 points (P < .001). The 3 most frequent sports activities were hiking, biking, and swimming. Conclusion There was a significant increase of sports activity by treating ankle arthritis patients with total ankle replacement. Sports-active total ankle replacement patients showed better functional results than did inactive ones.

Snowboarder’s Talus Fracture Treatment Outcome of 20 Cases After 3.5 Years

Background Fracture of the lateral process of the talus is a typical snowboarding injury. Basic data are limited, particularly with respect to treatment and outcome. Hypothesis As the axial-loaded dorsiflexed foot becomes externally rotated and/or everted, fracture of the lateral process of the talus occurs. Primary surgical treatment may improve the outcome of this injury, reducing the risk of secondary subtalar joint osteoarthritis. Study Design Cohort study; Level of evidence, 2. Methods We recorded details of the treatment and evaluation of 20 patients (8 female and 12 male; age at trauma, 29 years [range, 17-48 years]) who sustained a lateral process of the talus fracture while snowboarding. The injury pathomechanism was documented. The patients were treated either nonsurgically or surgically based on a fracture-type treatment algorithm. The evaluation at most recent follow-up (mean, 42 months [range, 26-53 months]) included clinical and functional examination, follow-up of sport activity, and radiological assessment (radiograph, computed tomography scan). Results The injury mechanism included axial impact (100%), dorsiflexion (95%), external rotation (80%), and eversion (45%). Using the American Orthopaedic Foot and Ankle Society hindfoot score, the patients obtained a mean of 93 points; the surgically treated group (n = 14) scored higher (97 points) than did the nonoperative group (n = 6; 85 points) (P <. 05). Degenerative disease of the subtalar joint was found in 3 patients (15%; operative, 1 patient; nonoperative, 2 patients). All but 4 (20%, all after nonsurgical treatment) patients reached the same sport activity level as before injury. Conclusion The snowboarding-related lateral process of the talus fracture represents a complex hindfoot injury. In type II fractures, primary surgical treatment has led to achieving better outcomes, reducing sequelae, and allowing patients to regain the same sports activity level as before injury.

Korrekturosteotomien am distalen Unterschenkel und Rückfuß

ZusammenfassungAus der asymmetrischen Belastung des tibiotalaren Gelenks resultieren häufig Knorpelschäden, auf deren Boden sich eine progressive Arthrose entwickeln kann. Zwar sind rekonstruktive Operationsverfahren mit Korrekturosteotomien supra- und inframalleolär möglich; im Gegensatz zu anderen Gelenken liegen jedoch bislang nur rudimentäre Daten hinsichtlich Evidenz solcher Osteotomien vor. Das Ziel des vorliegenden Artikels ist es, allgemeine Überlegungen zu Korrekturosteotomien am distalen Unterschenkel und Rückfuß für die Behandlung von Knorpelschäden des Sprunggelenks darzustellen und einen Algorhithmus für das technische Vorgehen zu erarbeiten. Schließlich sollen zusätzliche Maßnahmen zur Rekonstruktion des deformierten und unphysiologisch belasteten Rückfußes kritisch diskutiert werden.Prinzipiell sind aufklappende und zuklappende supramalleoläre Korrekturosteotomien in einer oder mehreren Ebenen (sagittal, frontal oder transversal) möglich. Häufig ist allerdings zusätzlich eine inframalleoläre Korrekturosteotomie, in der Regel eine Kalkaneusosteotomie, notwendig, um eine regelrechte Fußstellung zu erlangen. Liegt zusätzlich eine Dysbalance der Weichteile mit insuffizienten Bändern und Sehnen oder auch Kontrakturen, namentlich auf der medialen Seite bei der Varusfehlstellung vor, müssen diese Probleme auch adressiert werden.Anhand eigener Daten konnten wir aufzeigen, dass Osteotomien um das Sprunggelenk die Stellung und Belastung des tibiotalaren Gelenks nachhaltig verbessern und einen weiteren Verschleiß des Knorpels hinauszögern können. In vielen Fällen konnte aufgrund einer Verbreiterung des Gelenkspalts gar eine Regeneration des Knorpels vermutet werden. Damit konnte eine verfrühte Definitivbehandlung mittels Arthrodese oder Endoprothese erfolgreich hinausgeschoben werden. Die besondere Bedeutung dieser Therapieoption liegt darin, dass sehr viele Patienten mit Beschwerden am Rückfuß eine idiopatische oder posttraumatische Achsenfehlstellung aufweisen. Zudem sind, insbesondere bei jüngeren oder aktiven Patienten, die Langzeitergebnisse der Arthrodese und der Endoprothese kritisch zu beurteilen. Demzufolge ist heute unsere Behandlungsstrategie, zunächst eine umfassende Korrektur der Fehlstellung durchzuführen, mit dem Ziel, ein regelrecht ausgerichtetes und stabiles Sprunggelenk zu erhalten. Dies erlaubt, falls erforderlich in einem späteren Schritt, eine Endoprothese zu implantieren.AbstractAsymmetric load of the ankle joint often results in degenerative disease. Although reconstructive surgery, including osteotomies above and beneath the tibiotalar joint, is possible, there are little data with respect to its evidence. This article presents general considerations for osteotomies around the osteoarthritic ankle and elaborates a rationale for the technical procedure. Additional measures for correcting the deformed and malaligned hindfoot are also elucidated.As a principle, opening-wedge and closing-wedge osteotomies are possible in one or more planes. In some instances, inframalleolar osteotomies are also necessary to achieve proper alignment of the foot. If present, imbalance of soft tissues, such as incompetence of ligaments and insufficiency of tendons, must also be addressed.Our results have shown that osteotomies above and beneath the ankle joint are able to correct deformities and incongruencies at the tibiotalar joint over the years, thus avoiding further cartilage wear. In some patients, the tibiotalar joint regained a regular joint space that can be attributed to potential regeneration of cartilage. In all but a few cases (<5%), arthrodesis or total ankle replacement has been successfully avoided. This benefit is even more important because mostly younger, active patients are involved, and long-term results after arthrodesis and total ankle replacement are critical. Therefore, our treatment strategy is to correct the deformity first to achieve a well-aligned and balanced tibiotalar joint. If necessary, total ankle replacement is considered in a second stage.Asymmetric load of the ankle joint often results in degenerative disease. Although reconstructive surgery, including osteotomies above and beneath the tibiotalar joint, is possible, there are little data with respect to its evidence. This article presents general considerations for osteotomies around the osteoarthritic ankle and elaborates a rationale for the technical procedure. Additional measures for correcting the deformed and malaligned hindfoot are also elucidated. As a principle, opening-wedge and closing-wedge osteotomies are possible in one or more planes. In some instances, inframalleolar osteotomies are also necessary to achieve proper alignment of the foot. If present, imbalance of soft tissues, such as incompetence of ligaments and insufficiency of tendons, must also be addressed. Our results have shown that osteotomies above and beneath the ankle joint are able to correct deformities and incongruencies at the tibiotalar joint over the years, thus avoiding further cartilage wear. In some patients, the tibiotalar joint regained a regular joint space that can be attributed to potential regeneration of cartilage. In all but a few cases (<5%), arthrodesis or total ankle replacement has been successfully avoided. This benefit is even more important because mostly younger, active patients are involved, and long-term results after arthrodesis and total ankle replacement are critical. Therefore, our treatment strategy is to correct the deformity first to achieve a well-aligned and balanced tibiotalar joint. If necessary, total ankle replacement is considered in a second stage.

Osteotomies of the distal tibia and hindfoot for ankle realignment

ZusammenfassungAus der asymmetrischen Belastung des tibiotalaren Gelenks resultieren häufig Knorpelschäden, auf deren Boden sich eine progressive Arthrose entwickeln kann. Zwar sind rekonstruktive Operationsverfahren mit Korrekturosteotomien supra- und inframalleolär möglich; im Gegensatz zu anderen Gelenken liegen jedoch bislang nur rudimentäre Daten hinsichtlich Evidenz solcher Osteotomien vor. Das Ziel des vorliegenden Artikels ist es, allgemeine Überlegungen zu Korrekturosteotomien am distalen Unterschenkel und Rückfuß für die Behandlung von Knorpelschäden des Sprunggelenks darzustellen und einen Algorhithmus für das technische Vorgehen zu erarbeiten. Schließlich sollen zusätzliche Maßnahmen zur Rekonstruktion des deformierten und unphysiologisch belasteten Rückfußes kritisch diskutiert werden.Prinzipiell sind aufklappende und zuklappende supramalleoläre Korrekturosteotomien in einer oder mehreren Ebenen (sagittal, frontal oder transversal) möglich. Häufig ist allerdings zusätzlich eine inframalleoläre Korrekturosteotomie, in der Regel eine Kalkaneusosteotomie, notwendig, um eine regelrechte Fußstellung zu erlangen. Liegt zusätzlich eine Dysbalance der Weichteile mit insuffizienten Bändern und Sehnen oder auch Kontrakturen, namentlich auf der medialen Seite bei der Varusfehlstellung vor, müssen diese Probleme auch adressiert werden.Anhand eigener Daten konnten wir aufzeigen, dass Osteotomien um das Sprunggelenk die Stellung und Belastung des tibiotalaren Gelenks nachhaltig verbessern und einen weiteren Verschleiß des Knorpels hinauszögern können. In vielen Fällen konnte aufgrund einer Verbreiterung des Gelenkspalts gar eine Regeneration des Knorpels vermutet werden. Damit konnte eine verfrühte Definitivbehandlung mittels Arthrodese oder Endoprothese erfolgreich hinausgeschoben werden. Die besondere Bedeutung dieser Therapieoption liegt darin, dass sehr viele Patienten mit Beschwerden am Rückfuß eine idiopatische oder posttraumatische Achsenfehlstellung aufweisen. Zudem sind, insbesondere bei jüngeren oder aktiven Patienten, die Langzeitergebnisse der Arthrodese und der Endoprothese kritisch zu beurteilen. Demzufolge ist heute unsere Behandlungsstrategie, zunächst eine umfassende Korrektur der Fehlstellung durchzuführen, mit dem Ziel, ein regelrecht ausgerichtetes und stabiles Sprunggelenk zu erhalten. Dies erlaubt, falls erforderlich in einem späteren Schritt, eine Endoprothese zu implantieren.AbstractAsymmetric load of the ankle joint often results in degenerative disease. Although reconstructive surgery, including osteotomies above and beneath the tibiotalar joint, is possible, there are little data with respect to its evidence. This article presents general considerations for osteotomies around the osteoarthritic ankle and elaborates a rationale for the technical procedure. Additional measures for correcting the deformed and malaligned hindfoot are also elucidated.As a principle, opening-wedge and closing-wedge osteotomies are possible in one or more planes. In some instances, inframalleolar osteotomies are also necessary to achieve proper alignment of the foot. If present, imbalance of soft tissues, such as incompetence of ligaments and insufficiency of tendons, must also be addressed.Our results have shown that osteotomies above and beneath the ankle joint are able to correct deformities and incongruencies at the tibiotalar joint over the years, thus avoiding further cartilage wear. In some patients, the tibiotalar joint regained a regular joint space that can be attributed to potential regeneration of cartilage. In all but a few cases (<5%), arthrodesis or total ankle replacement has been successfully avoided. This benefit is even more important because mostly younger, active patients are involved, and long-term results after arthrodesis and total ankle replacement are critical. Therefore, our treatment strategy is to correct the deformity first to achieve a well-aligned and balanced tibiotalar joint. If necessary, total ankle replacement is considered in a second stage.Asymmetric load of the ankle joint often results in degenerative disease. Although reconstructive surgery, including osteotomies above and beneath the tibiotalar joint, is possible, there are little data with respect to its evidence. This article presents general considerations for osteotomies around the osteoarthritic ankle and elaborates a rationale for the technical procedure. Additional measures for correcting the deformed and malaligned hindfoot are also elucidated. As a principle, opening-wedge and closing-wedge osteotomies are possible in one or more planes. In some instances, inframalleolar osteotomies are also necessary to achieve proper alignment of the foot. If present, imbalance of soft tissues, such as incompetence of ligaments and insufficiency of tendons, must also be addressed. Our results have shown that osteotomies above and beneath the ankle joint are able to correct deformities and incongruencies at the tibiotalar joint over the years, thus avoiding further cartilage wear. In some patients, the tibiotalar joint regained a regular joint space that can be attributed to potential regeneration of cartilage. In all but a few cases (<5%), arthrodesis or total ankle replacement has been successfully avoided. This benefit is even more important because mostly younger, active patients are involved, and long-term results after arthrodesis and total ankle replacement are critical. Therefore, our treatment strategy is to correct the deformity first to achieve a well-aligned and balanced tibiotalar joint. If necessary, total ankle replacement is considered in a second stage.

Muscular lower leg asymmetry in middle-aged people

Background: The purpose of this study was to determine whether muscular asymmetries were present in the lower legs of recreationally active middle-aged people grouped by leg dominance. Methods: Twelve healthy middle-aged subjects were analyzed bilaterally. The clinical variables included leg dominance, sports level, range of motion, lower leg alignment, calf circumference, and AOFAS (American Orthopaedic Foot and Ankle Society) ankle score. The biomechanical variables included maximal voluntary isometric ankle joint torque and surface electromyography (EMG) with determination of mean EMG frequency and intensity of four lower leg muscles: anterior tibial (AT), medial gastrocnemius (MG), soleus (SO), and peroneus longus (PL). Results: The mean EMG frequency was significantly lower in the dominant leg for the AT (dominant, 148.6 Hz; nondominant, 157.8 Hz) and MG muscles (dominant, 183.9 Hz; nondominant, 196.8 Hz). A significantly higher plantarflexion torque was found in the dominant leg (27.1 Nm) compared to the nondominant leg (22.9 Nm). Higher (not significant) dorsiflexion torque was found in the dominant leg (dominant, 27.3 Nm; nondominant, 24.8 Nm). The calf circumference was marginally significantly higher (p = 0.039) in the dominant leg (34.2 cm; nondominant leg, 33.8 cm). The dominant leg had a higher but not significantly different mean EMG intensity for all four muscles. Conclusions and Clinical Relevance: Differences in muscle EMG and torque were found between the dominant and nondominant lower leg. These results might be applicable to treatment, rehabilitation, and future research of lower leg and foot and ankle disorders.

Anatomische und biomechanische Überlegungen zur Sprunggelenkprothetik

ZusammenfassungDer Erfolg des prothetischen Ersatzes des oberen Sprunggelenks (OSG) dürfte wesentlich davon abhängen inwieweit die physiologischen Verhältnisse des Gelenks erhalten bleiben, respektive wiederhergestellt wurden. Je mehr das Design der Prothese der physiologischen Anatomie entspricht, je korrekter die Achsenstellung des Rückfußes und je ausgeglichener die Bandspannung ist, desto besser werden die normalen kinematischen Verhältnisse des OSG nachgeahmt. Dadurch können unphysiologische Kräfte vermindert werden, die zu Schmerzen, Verschleiß und zu einem frühen Implantatversagen führen können.In diesem Artikel sind die zur Sprunggelenkprothetik notwendigen anatomischen und biomechanischen Grundlagen zusammengestellt.AbstractThe success of total ankle replacement highly depends on how successfully the physiological kinematics are maintained or reconstructed. Normal kinematics of the ankle joint can be replicated by designing an implant that is as close as possible to the normal bony anatomy, aligning the ankle and balancing the ligaments. Mimicking normal kinematics and kinetics of a healthy ankle joint will consequently decrease damaging joint contact stress forces and stress forces on the surrounding soft tissue, which may cause wear, implant failure, and pain.This article summarizes the anatomical and biomechanical basics that are required in total ankle replacement.

Sprunggelenkprothese bei Varusarthrose

Coronal plane deformity has been found to be one of the main risk factors for poor clinical results, higher complication rates and failure of total ankle replacements. Initially, many authors considered a malalignment of more than 10° to be a contraindication for total ankle replacement, however, several publications later underlined the usefulness of the distinction of different etiologies of hindfoot malalignment. This subsequently led to suggestions for additional procedures in order to avoid early implant failure.The aim of the present article is to illustrate the different causes of varus malaligned arthritic ankles and to present procedures to balance these ankles at the time of replacement.ZusammenfassungEin Hauptrisikofaktor für ein frühzeitiges Implantatversagen nach Versorgung mit einer Sprunggelenkprothese sind Achsenfehlstellungen. Diese führen zu schlechten klinischen Resultaten, höheren postoperativen Komplikationsraten und Lockerungen. Deshalb wurde lange Zeit von vielen Autoren eine präoperative Fehlstellung von mehr als 10° als Kontraindikation für die prothetische Versorgung des oberen Sprunggelenks angesehen. Aus neueren Erkenntnissen zu den Fehlstellungen am Rückfuß sind in der Folge zahlreiche Zusatzeingriffe definiert worden, welche die Prothesenimplantation auch bei arthritischen Sprunggelenken mit Fehlstellungen zulassen.Ziel dieses Artikels ist es, die unterschiedlichen Ätiologien von Varusarthrosen aufzuarbeiten und deren Therapie im Hinblick auf die prothetische Versorgung des oberen Sprunggelenks zusammenzufassen.AbstractCoronal plane deformity has been found to be one of the main risk factors for poor clinical results, higher complication rates and failure of total ankle replacements. Initially, many authors considered a malalignment of more than 10° to be a contraindication for total ankle replacement, however, several publications later underlined the usefulness of the distinction of different etiologies of hindfoot malalignment. This subsequently led to suggestions for additional procedures in order to avoid early implant failure.The aim of the present article is to illustrate the different causes of varus malaligned arthritic ankles and to present procedures to balance these ankles at the time of replacement.

Total ankle replacement for varus deformity

Coronal plane deformity has been found to be one of the main risk factors for poor clinical results, higher complication rates and failure of total ankle replacements. Initially, many authors considered a malalignment of more than 10° to be a contraindication for total ankle replacement, however, several publications later underlined the usefulness of the distinction of different etiologies of hindfoot malalignment. This subsequently led to suggestions for additional procedures in order to avoid early implant failure.The aim of the present article is to illustrate the different causes of varus malaligned arthritic ankles and to present procedures to balance these ankles at the time of replacement.ZusammenfassungEin Hauptrisikofaktor für ein frühzeitiges Implantatversagen nach Versorgung mit einer Sprunggelenkprothese sind Achsenfehlstellungen. Diese führen zu schlechten klinischen Resultaten, höheren postoperativen Komplikationsraten und Lockerungen. Deshalb wurde lange Zeit von vielen Autoren eine präoperative Fehlstellung von mehr als 10° als Kontraindikation für die prothetische Versorgung des oberen Sprunggelenks angesehen. Aus neueren Erkenntnissen zu den Fehlstellungen am Rückfuß sind in der Folge zahlreiche Zusatzeingriffe definiert worden, welche die Prothesenimplantation auch bei arthritischen Sprunggelenken mit Fehlstellungen zulassen.Ziel dieses Artikels ist es, die unterschiedlichen Ätiologien von Varusarthrosen aufzuarbeiten und deren Therapie im Hinblick auf die prothetische Versorgung des oberen Sprunggelenks zusammenzufassen.AbstractCoronal plane deformity has been found to be one of the main risk factors for poor clinical results, higher complication rates and failure of total ankle replacements. Initially, many authors considered a malalignment of more than 10° to be a contraindication for total ankle replacement, however, several publications later underlined the usefulness of the distinction of different etiologies of hindfoot malalignment. This subsequently led to suggestions for additional procedures in order to avoid early implant failure.The aim of the present article is to illustrate the different causes of varus malaligned arthritic ankles and to present procedures to balance these ankles at the time of replacement.

Mediales Schmerzsyndrom nach Sprunggelenkprothesenimplantation

Total ankle replacement is an increasingly recommended treatment for patients with end-stage ankle osteoarthritis. The increasing experience with this procedure explains its acceptance as a therapeutic option in complex cases as part of reconstruction surgery. However, the complication rate including failure of the prosthesis should not be underestimated. Previous studies have shown that most patients developed ankle osteoarthritis secondary to previous trauma. Patients with posttraumatic osteoarthritis often have varus or valgus misalignment of the hindfoot. In cases with incorrectly addressed hindfoot misalignment and/or incorrectly positioned prosthesis components, pain may remain postoperatively because of biomechanical dysbalance and asymmetrical load. The pain is mostly localized on the medial side the so-called medial pain syndrome.The following classification of the medial pain syndrome has been established in our practice: type I medial impingement/contracture of medial ligaments, type II valgus deformity, type III varus deformity, type IV combined varus-valgus deformity.