Maik Hoberg

Attachment to laminin-111 facilitates transforming growth factor β-induced expression of matrix metalloproteinase-3 in synovial fibroblasts

Background: In the synovial membrane of patients with rheumatoid arthritis (RA), a strong expression of laminins and matrix degrading proteases was reported. Aim: To investigate the regulation of matrix metalloproteinases (MMPs) in synovial fibroblasts (SFs) of patients with osteoarthritis (OA) and RA by attachment to laminin-1 (LM-111) and in the presence or absence of costimulatory signals provided by transforming growth factor β (TGFβ). Methods: SFs were seeded in laminin-coated flasks and activated by addition of TGFβ. The expression of genes was investigated by quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR), immunocytochemistry and ELISA, and intracellular signalling pathways by immunoblotting, and by poisoning p38MAPK by SB203580, MEK-ERK by PD98059 and SMAD2 by A-83-01. Results: Attachment of SF to LM-111 did not activate the expression of MMPs, but addition of TGFβ induced a fivefold higher expression of MMP-3. Incubation of SF on LM-111 in the presence of TGFβ induced a significant 12-fold higher expression of MMP-3 mRNA, and secretion of MMP-3 was elevated 20-fold above controls. Functional blocking of LM-111–integrin interaction reduced the laminin-activated MMP-3 expression significantly. Stimulation of SF by LM-111 and TGFβ activated the p38MAPK, ERK and SMAD2 pathways, and inhibition of these pathways by using SB203580, PD98059 or A-83-01 confirmed the involvement of these pathways in the regulation of MMP-3. Conclusion: Attachment of SF to LM-111 by itself has only minor effects on the expression of MMP-1 or MMP-3, but it facilitates the TGFβ-induced expression of MMP-3 significantly. This mode of MMP-3 induction may therefore contribute to inflammatory joint destruction in RA independent of the proinflammatory cytokines interleukin (IL)1β or tumour necrosis factor (TNF)α.

Treatment of hallux valgus deformity

Hallux valgus deformity is a very common pathological condition which commonly produces painful disability. It is characterised as a combined deformity with a malpositioning of the first metatarsophalangeal joint caused by a lateral deviation of the great toe and a medial deviation of the first metatarsal bone. Taking the patient’s history and a thorough physical examination are important steps. Anteroposterior and lateral weight-bearing radiographs of the entire foot are crucial for adequate assessment in the treatment of hallux valgus. Non-operative treatment of the hallux valgus cannot correct the deformity. However, insoles and physiotherapy in combination with good footwear can help to control the symptoms. There are many operative techniques for hallux valgus correction. The decision on which surgical technique is used depends on the degree of deformity, the extent of degenerative changes of the first metatarsophalangeal joint and the shape and size of the metatarsal bone and phalangeal deviation. The role of stability of the first tarsometatarsal joint is controversial. Surgical techniques include the modified McBride procedure, distal metatarsal osteotomies, metatarsal shaft osteotomies, the Akin osteotomy, proximal metatarsal osteotomies, the modified Lapidus fusion and the hallux joint fusion. Recently, minimally invasive percutaneous techniques have gained importance and are currently being evaluated more scientifically. Hallux valgus correction is followed by corrective dressings of the great toe post-operatively. Depending on the procedure, partial or full weight-bearing in a post-operative shoe or cast immobilisation is advised. Post-operative radiographs are taken in regular intervals until osseous healing is achieved. Cite this article: Fraissler L, Konrads C, Hoberg M, Rudert M, Walcher M. Treatment of hallux valgus deformity. EFORT Open Rev 2016;1:295-302. DOI: 10.1302/2058-5241.1.000005.

[Painful hip arthroplasty: a diagnostic algorithm].

The number of implantations of hip prostheses in Germany is now approximately 190,000 per year. By improving the implants and the development of modern surgical techniques and instruments the revision rate has been significantly reduced. The survival rate of the implants could be further increased in recent years, however, up to 22% of patients complain about persistent pain after hip arthroplasty. The diagnosis of existing pain after total joint replacement of the hip joint to achieve a causal therapy needs a systematic approach because of the heterogeneity of the symptoms and diseases. The etiology of the pain can be joint-associated and also hip joint independent. Often the causes of pain are multifactorial so that a standardized assessment should be conducted using an algorithm. The clarification of pain begins with the history, inspection and palpation followed by a clinical examination. It is then useful to perform radiological imaging followed by invasive procedures if necessary. The exploratory revision is nowadays considered to be obsolete in the literature.ZusammenfassungPro Jahr werden in Deutschland ca. 190.000 Hüftendoprothesen implantiert. Durch die Verbesserung der Implantate und die Weiterentwicklung moderner Operationstechniken und -instrumente ist die prozentuale Lockerungsrate deutlich reduziert worden. Die Standzeiten der Implantate konnten in den letzten Jahren weiter erhöht werden, jedoch klagen bis zu 22% der Patienten nach Hüftprothesenimplantation über persistierende Schmerzen. Die Diagnostik bestehender Schmerzen nach endoprothetischer Versorgung des Hüftgelenks und die sich daraus ergebende kausale Therapie fordern aufgrund der Heterogenität der Ursachen eine systematische Vorgehensweise. Die Ätiologie der Schmerzen kann gelenkassoziiert als auch hüftgelenkunabhängig sein. Oft sind die Schmerzursachen multifaktoriell, sodass eine standardisierte Diagnostik anhand eines Algorithmus durchgeführt werden sollte. Die Klärung der Schmerzen beginnt mit der Anamnese, Inspektion, Palpation und wird gefolgt von der klinischen Untersuchung. Es schließen sich Bildgebung und falls erforderlich invasive Verfahren an. Die explorative Revision wird heutzutage in der Literatur als obsolet angesehen. In der vorliegenden Arbeit wird ein Algorithmus vorgestellt, mit dem man die Ursache der Schmerzen zielgerichtet erheben kann.AbstractThe number of implantations of hip prostheses in Germany is now approximately 190,000 per year. By improving the implants and the development of modern surgical techniques and instruments the revision rate has been significantly reduced. The survival rate of the implants could be further increased in recent years, however, up to 22% of patients complain about persistent pain after hip arthroplasty. The diagnosis of existing pain after total joint replacement of the hip joint to achieve a causal therapy needs a systematic approach because of the heterogeneity of the symptoms and diseases. The etiology of the pain can be joint-associated and also hip joint independent. Often the causes of pain are multifactorial so that a standardized assessment should be conducted using an algorithm. The clarification of pain begins with the history, inspection and palpation followed by a clinical examination. It is then useful to perform radiological imaging followed by invasive procedures if necessary. The exploratory revision is nowadays considered to be obsolete in the literature.

Acetabular defect classification in times of 3D imaging and patient-specific treatment protocols

Parallel to the rising number of revision hip procedures, an increasing number of complex periprosthetic osseous defects can be expected. Stable long-term fixation of the revision implant remains the ultimate goal of the surgical protocol. Within this context, an elaborate preoperative planning process including anticipation of the periacetabular defect form and size and analysis of the remaining supporting osseous elements are essential. However, detection and evaluation of periacetabular bone defects using an unsystematic analysis of plain anteroposterior radiographs of the pelvis is in many cases difficult. Therefore, periacetabular bone defect classification schemes such as the Paprosky system have been introduced that use standardized radiographic criteria to better anticipate the intraoperative reality. Recent studies were able to demonstrate that larger defects are often underestimated when using the Paprosky classification and that the intra- and interobserver reliability of the system is low. This makes it hard to compare results in terms of defects being studied. Novel software tools that are based on the analysis of CT data may provide an opportunity to overcome the limitations of native radiographic defect analysis. In the following article we discuss potential benefits of these novel instruments against the background of the obvious limitations of the currently used native radiographic defect analysis.ZusammenfassungParallel zur steigenden Anzahl der Revisionseingriffe am Hüftgelenk steigt auch die Anzahl der Patienten, die große periazetabuläre Knochendefekte aufweisen. Die adäquate chirurgische Versorgung solch komplexer Fälle mit einer stabilen und langfristigen Fixation des Revisionsimplantats bleibt oberstes Ziel. Hierzu ist eine präoperative Planung mit Abschätzung der Defektform und -größe sowie des verbleibenden autochthonen Knochenlagers essenziell. Die Detektion und Evaluation pfannenseitiger periprothetischer Knochendefekte durch unsystematische Beurteilung von konventionellen Beckenübersichtsaufnahmen ist jedoch in vielen Fällen nur unzureichend möglich. Zur vereinfachten präoperativen Planung wurden deshalb Klassifikationen wie die von Paprosky eingeführt, die standardisierte radiologische Evaluationskriterien anwenden, um den intraoperativ zu erwartenden Knochendefekt leichter einzuschätzen. Aktuelle Forschungsarbeiten konnten jedoch zeigen, dass diese Klassifikationssysteme die Größe der Defekte häufig unterschätzen und eine niedrige Intra- und Interobserverreliabilität aufweisen. Somit sind Ergebnisse unterschiedlicher Studien nur bedingt miteinander vergleichbar. Neuartige Software-Applikationen basierend auf der Analyse computertomographisch generierter Daten bieten Lösungsansätze für die Probleme, die mit der nativ-radiologischen Defektanalyse verbunden sind. Im folgenden Artikel wird der potenzielle Nutzen dieser neuartigen diagnostischen Instrumente vor dem Hintergrund der offensichtlichen Limitationen der bisher etablierten nativ-radiologischen Defektanalyse diskutiert.

Implantatschädigung durch Einsatz eines Hochfrequenzmessers

In revision surgery of joints, high-frequency electrocauterization instruments are used for homeostasis and dissection of soft tissue. If there is contact of these instruments with the metal implants, flashover can occur. This can lead to thermal microstructural changes in the material and as a consequence may reduce the fatigue strength of the implant. Four cases of hip revision surgeries were analysed. In all cases flashovers occurred and secondarily, the titanium hip endoprosthesis stem broke in the neck section of the prosthesis. The conducted investigations showed that contact between the high-frequency instrument and the anterolateral aspect of the endoprosthesis neck had occurred. Electrothermal implant damage was found in the broken area. If in hip revision surgery the stem is not to be replaced, contact between high-frequency instruments and the metal implant should be avoided.

Hüftgelenkendoprothetik bei kongenitaler Dysplasie

ZusammenfassungBei fortgeschrittener, symptomatischer Koxarthrose nach residueller Hüftgelenkdysplasie stellt die Implantation einer Endoprothese für die meisten Patienten die Therapieoption der Wahl dar. Die Komplexität dieses Eingriffs wird jedoch durch die anatomischen Besonderheiten des dysplastischen Hüftgelenks signifikant erhöht. Das relativ junge Patientenalter macht zudem eine begrenzte Standzeit des Implantats wahrscheinlich. Unter biomechanischen Gesichtspunkten sollte das primäre chirurgische Ziel die Rekonstruktion des anatomischen Drehzentrums sein. Die Pfanne sollte möglichst nahe am anatomischen Azetabulum implantiert werden. Zur suffizienten Stabilisierung der Pfanne stehen verschiedene operative Strategien zur Verfügung. Der anterolaterale Azetabulumdefekt kann durch eine Pfannendachplastik mit strukturellem oder spongiösem Autograft behoben werden. Auch eine kontrollierte Medialisierung der Pfanne oder die Implantation von Abstützpfannen und ovalen Sonderpfannen sind beschrieben. Eine zementlose biologische Fixierung der Pfanne führt insbesondere bei den überwiegend jungen Patienten zu besseren Langzeitergebnissen als eine zementierte Pfannenfixierung. Die Art der femoralen Rekonstruktion ist abhängig vom erwünschten Beinlängenausgleich und der Höhe des rekonstruierten Azetabulums. In einigen Fällen muss eine femorale Verkürzungsosteotomie durchgeführt werden. Im vorliegenden Artikel werden die Möglichkeiten der endoprothetischen Rekonstruktion in Abhängigkeit von der vorliegenden femoralen und azetabulären Deformität aufgezeigt.AbstractTotal hip arthroplasty is the procedure of choice for most patients with advanced, symptomatic osteoarthritis due to congenital dysplasia of the hip. However, the complexity of arthroplasty is significantly increased because of anatomic abnormalities associated with dysplasia of the hip. In addition the relatively young age of patients may affect survival of the implant. From a biomechanical standpoint the primary surgical objective is reconstruction of the anatomical center of rotation. Independent of the pelvic bone stock the socket should be located as near as possible to the anatomical acetabular location. There are various operative strategies to ascertain sufficient stability of the socket. The anterolateral deficiency of the acetabulum can be reconstructed by bulk femoral autografting or bone impaction grafting. Furthermore controlled perforation of the medial wall or implantation of reinforcement rings and oval sockets have been described. Cementless, biological socket fixation shows superior long-term results compared to cemented cups, especially in these young patients. The location of the reconstructed acetabulum and the desired leg length influence the type of femoral reconstruction and in some cases femoral shortening is required. In this article endoprosthetic reconstructive options for developmental dysplasia of the hip are discussed depending on the femoral and acetabular deformity.Total hip arthroplasty is the procedure of choice for most patients with advanced, symptomatic osteoarthritis due to congenital dysplasia of the hip. However, the complexity of arthroplasty is significantly increased because of anatomic abnormalities associated with dysplasia of the hip. In addition the relatively young age of patients may affect survival of the implant. From a biomechanical standpoint the primary surgical objective is reconstruction of the anatomical center of rotation. Independent of the pelvic bone stock the socket should be located as near as possible to the anatomical acetabular location. There are various operative strategies to ascertain sufficient stability of the socket. The anterolateral deficiency of the acetabulum can be reconstructed by bulk femoral autografting or bone impaction grafting. Furthermore controlled perforation of the medial wall or implantation of reinforcement rings and oval sockets have been described. Cementless, biological socket fixation shows superior long-term results compared to cemented cups, especially in these young patients. The location of the reconstructed acetabulum and the desired leg length influence the type of femoral reconstruction and in some cases femoral shortening is required. In this article endoprosthetic reconstructive options for developmental dysplasia of the hip are discussed depending on the femoral and acetabular deformity.

[Total knee arthroplasty. Patient-specific instruments and implants].

ZusammenfassungDieser Beitrag beschreibt die Konzeption und die operative Technik der patientenspezifischen totalen Kniegelenksendoprothetik. Patientenindividuelle Implantate und Instrumente werden auf der Basis einer Computertomographie (CT) des Beins entworfen und hergestellt. Patientenspezifische Einweginstrumente in Form von Bohrschablonen und Schnittblöcken berücksichtigen die anatomischen und mechanischen Achsen des Kniegelenks und vermitteln eine effiziente Pränavigation der knöchernen Schnitte, ohne dass zusätzliche Navigations- oder Balancierungshilfen notwendig sind. Die Operationsplanung erfolgt anhand der CT-Datensätze. Die Implantationstechnik beinhaltet die Teilschritte distale Femurresektion, Tibiaresektion, Balancieren und Femurpräparation, Tibiapräparation, optionaler Patellarückflächenersatz, Testung der Probekomponenten und Implantation der endgültigen Implantatkomponenten. Durch die Verwendung dieses patientenspezifischen Implantatsystems, das nicht nur die personalisierten Einmalinstrumente, sondern auch die individuellen Implantate beinhaltet, wird dem Chirurgen eine endoprothetische Versorgung ermöglicht, die die patientenindividuelle Anatomie und Kniegelenkskinematik in weiten Teilen wiederherstellt. Vorläufige Studien belegen das Konzept und die bisherige Datenlage mit dieser Technologie ist vielversprechend, wenn auch, wie bei einem jungen Implantat üblich, begrenzt. Insbesondere stehen vergleichende Langzeitstudienergebnisse derzeit noch aus.AbstractThis article describes the concept and surgical technique of patient-specific total knee arthroplasty. Patient-specific implants and instruments are designed and fabricated based on computed tomography (CT) data of the leg. The disposable patient-specific drill guides and cutting-jigs are manufactured taking into consideration the anatomical and biomechanical axes of the knee joint and mediating the efficient pre-navigation of the osseous saw-cuts, without the need for additional navigation or balancing aids. The surgical plan is made on the basis of the CT data. The implantation technique comprises the following steps: distal femoral resection, tibial resection, balancing and femur preparation, tibia preparation, optional patellar resurfacing, trialling of the test components, and implantation of the final components. By using this patient-specific implant system, which includes not only personalized, single-use instruments, but also individualized implants, the surgeon is able to provide endoprosthetic treatment that broadly restores the patient’s own knee anatomy and knee kinematics. Preliminary studies have proven the concept and data on this technology are promising so far; however, like a new implant, they are usually limited. In particular, comparative long-term clinical data are still to come.This article describes the concept and surgical technique of patient-specific total knee arthroplasty. Patient-specific implants and instruments are designed and fabricated based on computed tomography (CT) data of the leg. The disposable patient-specific drill guides and cutting-jigs are manufactured taking into consideration the anatomical and biomechanical axes of the knee joint and mediating the efficient pre-navigation of the osseous saw-cuts, without the need for additional navigation or balancing aids. The surgical plan is made on the basis of the CT data. The implantation technique comprises the following steps: distal femoral resection, tibial resection, balancing and femur preparation, tibia preparation, optional patellar resurfacing, trialling of the test components, and implantation of the final components. By using this patient-specific implant system, which includes not only personalized, single-use instruments, but also individualized implants, the surgeon is able to provide endoprosthetic treatment that broadly restores the patients own knee anatomy and knee kinematics. Preliminary studies have proven the concept and data on this technology are promising so far; however, like a new implant, they are usually limited. In particular, comparative long-term clinical data are still to come.

Individualendoprothetik am Kniegelenk

This article describes the rationale and the surgical technique of patient-specific uni-, bi-, or three-compartmental knee arthroplasty using the second generation (G2) of ConforMIS™ technology. The patient-individual implants and instruments are designed and fabricated based on data from a preoperative computed tomography of the lower limb. The disposable patient-specific drill guides and cutting-jigs are manufactured under consideration of the anatomical and biomechanical axes of the knee joint and mediate efficient pre-navigation of the saw-cuts on the femoral and tibial bone without the need for an additional navigation or balancing device. The surgical technique for all types of knee resurfacement comprises the steps of cartilage removal, knee balancing in extension and flexion, sparing bony cuts, final preparation of femur and tibia, trialling, cementing of components and final choice of tibial insert. The use of individualized three-dimensional image-derived resurfacing implants, as well as personalized single-use instrumentation, facilitates the surgeon to perform an almost anatomical knee resurfacement that has the potential to restore almost normal knee kinematics. The limited data on this novel technology is promising, however long-term clinical data is needed for final evaluation of this technology.ZusammenfassungIn dieser Arbeit wird die grundlegende Rationale und die chirurgische Technik der patientenspezifischen uni-, bi- und trikompartimentellen Kniegelenksendoprothetik mit der zweiten Generation der ConforMIS™-Technologie beschrieben. Patientenindividuelle Implantate und Instrumente werden auf der Basis eines speziellen Computertomogrammes des Beines entworfen und hergestellt. Patientenspezifische Einweginstrumente in Form von Bohrschablonen und Schnittblöcken berücksichtigen die anatomischen und mechanischen Achsen des Kniegelenkes und vermitteln eine effiziente Pränavigation der knöchernen Schnitte, ohne dass zusätzliche Navigations- oder Balancierungshilfen notwendig sind. Die Implantationstechnik für alle individuellen Implantate beinhaltet die Teilschritte Knorpelentfernung, Ausbalancieren des Kniegelenkes, dosierte Knochenschnitte, Präparation des femoralen und tibialen Implantatlagers, Testung der Probekomponenten, Zementieren der endgültigen Komponenten und Wahl der besten Inlayhöhe. Durch die Verwendung dieses patientenspezifischen Implantatsystems, welches nicht nur die individuellen Einmalinstrumente, sondern auch die individuellen Kniegelenksimplantate beinhaltet, wird dem Chirurgen eine endoprothetische Versorgung ermöglicht, welche die patientenindividuelle Anatomie und Kniegelenkkinematik optimal wiederherstellt. Die bisherige begrenzte Datenlage mit dieser Technologie ist vielversprechend, jedoch stehen klinische Langzeitergebnisse derzeit noch aus.AbstractThis article describes the rationale and the surgical technique of patient-specific uni-, bi-, or three-compartmental knee arthroplasty using the second generation (G2) of ConforMIS™ technology. The patient-individual implants and instruments are designed and fabricated based on data from a preoperative computed tomography of the lower limb. The disposable patient-specific drill guides and cutting-jigs are manufactured under consideration of the anatomical and biomechanical axes of the knee joint and mediate efficient pre-navigation of the saw-cuts on the femoral and tibial bone without the need for an additional navigation or balancing device. The surgical technique for all types of knee resurfacement comprises the steps of cartilage removal, knee balancing in extension and flexion, sparing bony cuts, final preparation of femur and tibia, trialling, cementing of components and final choice of tibial insert. The use of individualized three-dimensional image-derived resurfacing implants, as well as personalized single-use instrumentation, facilitates the surgeon to perform an almost anatomical knee resurfacement that has the potential to restore almost normal knee kinematics. The limited data on this novel technology is promising, however long-term clinical data is needed for final evaluation of this technology.

Individualized total knee arthroplasty

This article describes the rationale and the surgical technique of patient-specific uni-, bi-, or three-compartmental knee arthroplasty using the second generation (G2) of ConforMIS™ technology. The patient-individual implants and instruments are designed and fabricated based on data from a preoperative computed tomography of the lower limb. The disposable patient-specific drill guides and cutting-jigs are manufactured under consideration of the anatomical and biomechanical axes of the knee joint and mediate efficient pre-navigation of the saw-cuts on the femoral and tibial bone without the need for an additional navigation or balancing device. The surgical technique for all types of knee resurfacement comprises the steps of cartilage removal, knee balancing in extension and flexion, sparing bony cuts, final preparation of femur and tibia, trialling, cementing of components and final choice of tibial insert. The use of individualized three-dimensional image-derived resurfacing implants, as well as personalized single-use instrumentation, facilitates the surgeon to perform an almost anatomical knee resurfacement that has the potential to restore almost normal knee kinematics. The limited data on this novel technology is promising, however long-term clinical data is needed for final evaluation of this technology.ZusammenfassungIn dieser Arbeit wird die grundlegende Rationale und die chirurgische Technik der patientenspezifischen uni-, bi- und trikompartimentellen Kniegelenksendoprothetik mit der zweiten Generation der ConforMIS™-Technologie beschrieben. Patientenindividuelle Implantate und Instrumente werden auf der Basis eines speziellen Computertomogrammes des Beines entworfen und hergestellt. Patientenspezifische Einweginstrumente in Form von Bohrschablonen und Schnittblöcken berücksichtigen die anatomischen und mechanischen Achsen des Kniegelenkes und vermitteln eine effiziente Pränavigation der knöchernen Schnitte, ohne dass zusätzliche Navigations- oder Balancierungshilfen notwendig sind. Die Implantationstechnik für alle individuellen Implantate beinhaltet die Teilschritte Knorpelentfernung, Ausbalancieren des Kniegelenkes, dosierte Knochenschnitte, Präparation des femoralen und tibialen Implantatlagers, Testung der Probekomponenten, Zementieren der endgültigen Komponenten und Wahl der besten Inlayhöhe. Durch die Verwendung dieses patientenspezifischen Implantatsystems, welches nicht nur die individuellen Einmalinstrumente, sondern auch die individuellen Kniegelenksimplantate beinhaltet, wird dem Chirurgen eine endoprothetische Versorgung ermöglicht, welche die patientenindividuelle Anatomie und Kniegelenkkinematik optimal wiederherstellt. Die bisherige begrenzte Datenlage mit dieser Technologie ist vielversprechend, jedoch stehen klinische Langzeitergebnisse derzeit noch aus.AbstractThis article describes the rationale and the surgical technique of patient-specific uni-, bi-, or three-compartmental knee arthroplasty using the second generation (G2) of ConforMIS™ technology. The patient-individual implants and instruments are designed and fabricated based on data from a preoperative computed tomography of the lower limb. The disposable patient-specific drill guides and cutting-jigs are manufactured under consideration of the anatomical and biomechanical axes of the knee joint and mediate efficient pre-navigation of the saw-cuts on the femoral and tibial bone without the need for an additional navigation or balancing device. The surgical technique for all types of knee resurfacement comprises the steps of cartilage removal, knee balancing in extension and flexion, sparing bony cuts, final preparation of femur and tibia, trialling, cementing of components and final choice of tibial insert. The use of individualized three-dimensional image-derived resurfacing implants, as well as personalized single-use instrumentation, facilitates the surgeon to perform an almost anatomical knee resurfacement that has the potential to restore almost normal knee kinematics. The limited data on this novel technology is promising, however long-term clinical data is needed for final evaluation of this technology.

Total Ankle Replacement in Varus Ankle Osteoarthritits

About 50% of the cases with degenerative osteoarthritis of the ankle are asymmetric. Varus ankle osteoarthritis is far more frequent than valgus ankle osteoarthritis. Most of the cases of ankle osteoarthritis have posttraumatic aetiology. It is important to understand the deformity completely, and to distinguish simple deviations in the coronal plane from more-dimensional, complex cavovarus deformities involving the midfoot and the forefoot. Concomitant ligament and tendon imbalances and pathologies need to be identified and analysed. Correction planning needs to include the mechanical axis of the complete leg. Muscular imbalances need to be identified. Even substantial deformities in varus ankle osteoarthritis can be treated with total ankle replacement successfully, if a plantigrade foot with balanced ligaments and tendons can be achieved. The corrective procedure may include realigning osteotomies, fusions, and correction of tendon and ligament pathologies.