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The Journal of Foot & Ankle Surgery 51 (2012) 226–233

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The Journal of Foot & Ankle Surgery

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Step-cut Medial Malleolar Osteotomy: Literature Review and Case Reports

S. Jeffrey Siegel, DPM, FACFAS 1, Alexander C. Mount, BA 2

1Aria Health Systems Clerkship Coordinator and Temple University School of Podiatric Medicine, Philadelphia, PA2 Fourth-Year Student, Temple University School of Podiatric Medicine, Philadelphia, PA

a r t i c l e i n f o

Level of Clinical Evidence: 4Keywords:allograft transplantationankleosteochondral defect surgerytalar dometalus

Financial Disclosure: None reported.Conflict of Interest: None reported.Address correspondence to: S. Jeffrey Siegel,

Specialists of Bucks County, 3554 Holmeville Road, BE-mail address: heeldoc@verizon.net (S.J. Siegel).

1067-2516/$ - see front matter � 2012 by the Americdoi:10.1053/j.jfas.2011.10.009

a b s t r a c t

Talar dome pathology involving the medial half of the talus is a common occurrence. Direct visualization ofthis region of the ankle joint can be challenging because of anatomical constraints. Many lesions can be seenarthroscopically and, with the aid of a distractor, can be successfully treated. However, because of adhesivecapsulitis and/or the size and location of the lesion, an open arthrotomy or a transmedial malleolar osteotomymay be required. The purpose of this article is to review the literature on techniques developed for gainingaccess to this area of the ankle and to highlight the step-cut medial malleolar osteotomy (SCMMO) andmodifications that can be made to it to facilitate joint access. Two case studies are used to exemplify theSCMMO and modifications used to increase talar dome access. Because of anatomic constraints, many foot andankle surgeons recommend osteotomy of the medial malleolus to gain access to the posteromedial aspect ofthe ankle. The step-cut approach is technically simple to perform; it can be safely modified when treatingcentral lesions, it has inherent osseous stability that minimizes risk of displacement during rehabilitation, andit has a broad cancellous surface area, which facilitates osseous union. The authors recommend this procedurewhen an osteotomy is needed to gain access to the posteromedial ankle joint.

� 2012 by the American College of Foot and Ankle Surgeons. All rights reserved.

There is a fair amount of controversy regarding lesions of the talardomedwhat they should be called, the underlying etiology, how toclassify them, and how to best treat themdthere is dispute aboutboth the treatment and method by which the treatment should berendered. Given the variety of issues surrounding the talar dome, thisarticle will focus on lesions of the medial aspect of the talar dome.

Lesions of the talar dome have been called osteochondritisdissecans (1), flake fracture (2), chip fracture of the talus (3), osteo-chondral fracture (4), transchondral fracture of the talus (5), anddome fracture of the talus (6). Flick and Gould (7) found that 70% ofmedial lesions were associated with a history of trauma includingmild inversion ankle injuries. Other potential causes are use ofsteroids or alcohol, endocrine abnormalities, heredity, or emboli (8).

There are a variety of classification systems that have beenproposed. Generally speaking, Berndt and Harty’s (5) classification isthe most widely accepted, although other classifications exist (8–10).

The mechanism of injury for osteochondral lesions of the talardome is traditionally thought of in terms of Berndt and Harty’s 4-stageclassification system (5). On the medial aspect of the talar dome, themechanism of injury is that the tibia externally rotates on a fixedplantarflexed and inverted foot and, depending on the force and

DPM, FACFAS, Foot and Ankleensalem, PA 19020.

an College of Foot and Ankle Surgeon

energy of injury, will result in 1 of 4 stages. Stage 1 is a small area ofsubchondral compression, and in stage 2 a partially detached chipfracture of osteochondral bone occurs. In stage 3, a completelydetached, but anatomically aligned piece of osteochondral bone is inthe joint, and in stage 4 the osteochondral bone fragment is completelydetached and displaced or even flipped 180� from its anatomicalposition.

Conservative treatment options include but are not limited to restand restriction of activities, cast immobilization, physical therapy,corticosteroid injections, and bone stimulation (11). Surgical inter-vention can include excision of the loose body (if present) by itself orfollowed by curettage of the outlying necrotic tissue, with or withoutdrilling, or microfracture of the subchondral bone. In more severeor recalcitrant cases, cancellous bone grafting, or osteochondralautograft transplantation (OATS), autologous condrocyte implanta-tion, or fresh or frozen talar allograft transplantation are used. Eachof these various techniques can be rendered via arthroscopy (12–14), arthrotomy (7,12,15), or transchondral osteotomy (12,16–28).Arthroscopy-assisted percutaneous retrograde drilling through thetalus (12,29,30) or through a drill hole in themedial malleolus (30) arealso options.

In the context of talar dome pathology, lesions involving themedial half of the talus are a common occurrence. Berndt and Harty(5) found that 56.3% of 201 osteochondral lesions of the talar domewere located medially and were usually located in the posterior onethird. Similarly, Roden et al (14) found that 57% of 55 talar dome

s. All rights reserved.

Fig. 1. (A) Preoperative anteroposterior ankle radiograph and (B) coronal CAT scandemonstrate a comminuted osteochondral fracture on the posteromedial talar body witha loose posterior process.

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lesions were on the medial side and were also primarily located in theposterior one third. In a review of literature of 39 studies, 58% of talardome lesions were located medially (12). In a magnetic resonanceimaging (MRI) study of 424 patients with 428 osteochondral lesions ofthe talar dome, Raikin et al (31) found that 62.8% of the lesions werelocated medially. Contrary to the previously mentioned studies and

Fig. 2. Elevation and posterior retraction of the osteochondral fracture.

common wisdom, the majority of these medial lesions were centralmedial (53.0%), followed by posteromedial (6.8%), and anteromedial(3.0%). Many medial lesions can be seen arthroscopically and, withthe aid of a distractor, can be successfully treated. However, directvisualization of the posteromedial region of the ankle joint can bechallenging because of anatomical constraints and, in cases ofparticularly large lesions or limited joint access or range of motion, anopen arthrotomy or a transmedial malleolar osteotomy may berequired (16). In the senior author’s (SJS) experience, fibrous adhe-sions can limit joint distraction and may require arthrodiastasis. Thepurpose of this article is to review the literature on techniquesfor gaining access to this precarious area of the ankle joint and tohighlight the step-cut medial malleolar osteotomy and modificationsthat can be made to it to increase talar dome access (16–18). Two casereports are also reviewed.

Case Reports

The cases presented belowwere selected because they exemplifiedthe step-cut medial malleolar osteotomy and the modified versionused to increase talar dome access detailed below. The patients wereselected because they presented to the senior author’s practice andhad relevant pathology that was unresponsive to conservative care.The patients were followed up for a minimum of 15 months.

A literature review was performed using various combinations ofthe following keywords in PubMed: step-cut, talar dome, fracture,lesion, medial malleolar osteotomy, osteochondral lesion, OATS,osteochondritis dissecans, transchondral fracture, and talus. Thereference lists of the selected articles were also used to find otherarticles.

Case 1

A 31-year-old woman was admitted to the podiatry service com-plaining of severe right ankle pain 3 hours after she was involved ina restrained motor vehicle accident. Physical examination was unre-markable with the exception of pain, edema, and ecchymosis of herright ankle. There were no fracture blisters present.

Radiographic and computerized axial tomography (CAT) scan(Fig. 1) data revealed a large, 2.5 � 1.75 cm comminuted osteochon-dral fracture on the posteromedial talar body with a loose posteriorprocess fragment. After a thorough discussion of the risks, alterna-tives, and complications of surgery, open reduction with internalfixation via a step-cut medial malleolar osteotomy was performed inthe manner described. The large osteochondral fragment was

Fig. 3. Anatomical reduction of the osteochondral fracture.

Fig. 4. (A) Immediate postoperative radiograph demonstrating anatomical alignment. (B)At 6 weeks, the pins were removed and radiographs revealed bony consolidation.

Fig. 6. Central positioning of the vertical arm of the osteotomy allows for access to centrallesions as well as orthogonal positioning of an oscillating saw to debride the talus.

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elevated and retracted posteriorly (Fig. 2) while the hematoma andsmall bone fragments were removed. The loose posterior processfragment was not visualized during the procedure. The osteochondralfracture was anatomically reduced (Fig. 3), and three 0.045-inchKirschner wires (K-wires) were driven through the fracture, out theanterolateral talus, and then buried subcutaneously. The medialmalleolus was replaced and rigidly fixated (Fig. 4A).

Postoperative radiographs revealed anatomic reduction of thetalus. Early non–weight-bearing range-of-motion exercises werestarted at 2 weeks, partial weight-bearing at 6 weeks, and full weight-bearing at 10 weeks once the pins were removed (Fig. 4B). The patientwas back to full unrestricted activities by 6 months, but still hada focal area of tenderness in the posteromedial subtalar joint. Diag-nostic sinus tarsi anesthetic injections had relieved her pain. CAT scanrevealed union of both the medial malleolus and talar dome fracture.The remnant posterior process fragment became symptomatic andwas subsequently excised. At the 15-month follow-up visit, she wascompletely asymptomatic and enjoying all activities while wearingnormal shoe gear.

Case 2

A 38-year-old womanwith chronic right ankle painwas diagnosedwith a posteromedial talar dome osteochondral defect (OCD) lesionandwas initially treated arthroscopically. An external fixator provideddistraction, and anterior and posterior portals were utilized. Within

Fig. 5. CAT scan (A) and MRI (B) revealed multiple OCD lesions.

2 months after her procedure, her ankle pain recurred and sheessentially lived with the pain until she presented to our outpatientclinic 10 years later.

The patient’s subjective symptoms consisted of ankle pain with allweight-bearing activities, especially going up or down stairs, hills, orwhile standing on her tiptoes. Self-treatment consisted of physicaltherapy, immobilization with a CAM walker, braces, nonsteroidalanti-inflammatory drugs, ice, compression and elevation, topicalanalgesics, and over-the-counter arch supports.

Clinical examination revealed generalized nonpitting edema andnormal neurovascular status. There was no muscular weakness withmanual muscle testing. The range of motion of the subtalar andmidtarsal joints were full and unrestricted; however, ankle jointdorsiflexion was restricted with a bony end-feel. Pain was elicitedwith forced dorsiflexion and medial compression with motion of theankle joint.

Diagnostic ankle intra-articular anesthetic injection relieved 100%of the patient’s pain. Diagnostic studies consisted of radiographs that

Fig. 7. (A) Medial view of the diseased portion of talus, which was used to size an allograftfashioned from a 10-day-old talus (B).

Fig. 8. Three 20-mm-long low-profile 2.0-mm cortical screws were used to hold theallograft in place.

Fig. 10. Anterior view of the right talar dome during the osteophyte d�ebridement allowsvisualization of the incorporated allograft. D, donor graft; N, native talus.

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confirmed the presence of osseous equinus, whereas the CAT scan andMRI (Fig. 5) confirmed the diagnosis of multiple OCD lesions thatcommunicated with the ankle joint. The articular pathology involvedthe medial one third of the talus from anterior to posterior.

A modified step-cut medial malleolar osteotomy was used withthe vertical arm of the osteotomy positioned more centrally over thetalar dome (Fig. 6). This modification provided enough space to allowpositioning of an oscillating saw to make a vertical cut in the talardome. An osteotomewas used to make a horizontal cut to remove thediseased portion of the talus. The void was filled with an appropri-ately sized graft fashioned from a 10-day-old fresh female right talusallograft (Fig. 7), which was held in place with three 20-mmlow-profile 2-mm cortical screws (Fig. 8). The medial malleolus wasfixated with two 4.5-mm cannulated cancellous screws, one orientedobliquely and the other transversely (Fig. 9) across the osteotomy, andthe wound was closed.

The patient was non–weight-bearing for a total of 10 weeks.Physical therapy was initiated at 3 weeks, and at 10 weeks a CAT scanconfirmed the absence of avascular necrosis, complete incorporationof the donor graft, and osseous union of the osteotomy. Because ofanterior ankle impingement pain, the patient was taken back to theoperating room for debridement of the anterior distal tibial and talarneck osteophytes, hardware removal, and a second look at the graft.The fresh talar allograft was well incorporated and in good position,and its incorporation into the talar dome was practically

Fig. 9. Fluoroscopic images of (A) the modified step-cut medial malleolar osteotomy withthe vertical arm of the osteotomy positioned more centrally over the talar dome; (B) thefixation of medial malleolus with oblique and transverse screws.

imperceptible (Fig. 10). The patient has since returned to full, unre-stricted activities.

Operative Technique

General or spinal anesthesia is established, and the lowerextremity is prepped and draped in the usual aseptic manner.Prophylactic antibiotics are administered, and after exsanguination,a thigh tourniquet is inflated in the usual manner. Attention isdirected to the medial malleolus, where a 10-cm linear incision isperformed over the medial malleolus, curving slightly anteriorly atthe distal end (Fig. 11). Soft tissue dissection is then carried downthrough the deep fascia to the level of the deltoid ligament. Theperiosteum is bluntly dissected horizontally, superior to the deltoidligament to expose the anterior and posterior aspects of the medialankle joint as well as the joint gutter. This will enable definition of theanteromedial corner of the ankle joint. The saphenous nerve and veinare contained in the anterior flap and are retracted anteriorly.

At this time, a 2- to 3-cm incision is made in the posterior tibialtendonsheathwhere it coursesover themedialmalleolusanda1/4-inchpenrosedrain isused to retract the tendonposteriorly. A Freer elevator isused to identify the posteromedial corner of the ankle joint. Whileviewing the anklemortise anteriorly, a ruler is used tomark the verticallimb of the osteotomy approximately 1.5 cm directly superior to themedial corner of the mortise or as proximal as is necessary to avoiddisrupting the deltoid ligament. A second line is drawn from the apexofthe vertical limb perpendicularly to the medial border of the malleolus.This horizontal limb is then extended in a posterior direction across themalleolus (Fig. 12). At this time, 2 holes are predrilled parallel to oneanother, directed proximolaterally so that they intersect the junction ofthe vertical and horizontal arms. Doing so ensures future anatomicreduction. The typeoffixationused is at the surgeon’s discretion, but thesenior author prefers using 2 partially threaded 4.0-mm cancellous or4.5-mm cannulated cancellous screws. Regardless of the type of screws

Fig. 11. Incision placement with outline of medial malleolus on a cadaver model.

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used, they should be placed using proper Arbeitsgemeinschaft f€urOsteosynthesefragen (AO) technique.

Limited periosteal dissection is then used to expose the proposedosteotomy sites. An anteromedial capsulotomy is performed, anda 0.062-inch K-wire is inserted from anterior to posterior in the

Fig. 12. Saw bone demonstrating the vertical (A) and horizontal (B) limbs of the traditionalstep-cut medial malleolar osteotomy.

superomedial corner of the mortise. The K-wire acts as an axis guideand is held in place throughout the osteotomy. To minimize iatrogenictalar dome damage, the ankle joint should be plantarflexed while thebone cuts are being made. An oscillating saw is used to create thetransverse cut parallel to the K-wire and a 1-cm osteotome is used tocreate the vertical cut. By levering the osteotome, the medialmalleolus is pried off the tibia and a bone hook can then be used toretract the medial malleolus inferiorly using the deltoid ligament asa hinge (Fig. 13). Once the intra-articular procedure is completed, themalleolus is returned to its anatomic position and fixated via thepreviously placed drill holes (Fig. 14).

Discussion

Arthroscopic surgery for treatment of intra-articular ankle jointpathology is very effective (12). In some cases, however, access tolesions in the posteromedial ankle joint region can be difficultbecause of osteophytes, arthrofibrosis, and/or anatomic constraints.Arthroscopic access to this precarious area can be facilitated bya number of distraction techniques. Andrews (32) places theextremity in a knee holder with the end of the operating tabledropped 90�. Yates and Grana (33) do the preceding, but also placea loop of sterile Kerlix (Covidien, Mansfield, MA) around the ankleand apply a joint-distracting force with the surgeon’s or an assis-tant’s foot. This technique works well, but in the senior author’sexperience, a constant force is difficult to maintain throughout theentire case.

Other authors (34–37) flex the hip and knee, and position theextremity in a holder and then separate the ankle joint witha mechanical AO distractor. Iatrogenic complications such as instru-ment breakage, osteomyelitis, sinus tract formation, ligamentousdisruption, and occult fracture can occur. Use of an external fixator/distractor is also contraindicated in the presence of open physealplates. Although a posteromedial portal is possible, it carries with itthe risk of damaging the posterior tibial artery and nerve (30).

If these techniques fail, then an arthrotomy or medial malleolarosteotomy should be performed. Flick and Gould (7) were able toavoid osteotomy in 7 out of 8 medial lesions by entering the anklejoint through the anterior tibial tendon sheath, thereby avoidingthe neurovascular bundle. Visibility may be improved if the foot isplantarflexed down to a maximum equinus position (11). However, ifthe lesion is still not visible, the anteromedial articular surface of thetibia overlying the talar lesion is grooved with a narrow gouge (4).

Fig. 13. Medial view of the ankle. The talar dome is visualized once the medial malleolusis retracted inferiorly using the deltoid ligament as a hinge.

Fig. 14. Medial view of a cadaver model: Anatomic position of the medial malleolus isrestored once two 4.0-mm partially threaded cancellous screws are inserted.

Fig. 15. Bone cuts for the step-cut medial malleolar osteotomy. (A) Traditional step-cut.(B) Modification with laterally placed vertical arm for larger and more centralized talardome lesions.

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Most patients had good or excellent results. Iatrogenic fracture of thetibia, anterior tibial tendonitis, draining synovial sinus tract, anddegenerative joint disease are potential complications.

Thompson and Loomer (15) describe a combination anterior andposterior medial ankle joint arthrotomy technique. If the defectcannot be completely visualized or treated, an incision is made in theposterior tibial tendon sheath and the tendon is retracted anteriorly.An incision is made in the deep surface of the flexor retinaculum andthe tarsal canal contents are then retracted posteriorly. By maximallydorsiflexing the foot, the posterior half of the superomedial talus canbe readily observed and treated. The extensive soft tissue dissection ofthis approach can produce significant scar tissue leading to chronicedema, numbness, tendonitis, neuritis, or tarsal tunnel syndrome.Iatrogenic laceration of any of the soft tissue structures can lead tochronic pain and permanent disability.

Six transmedial malleolar osteotomy approaches have beenpreviously described in the literature. Some authors use a transverseosteotomy (19–23) in which a cut is made in the medial malleolus atthe level of the ankle joint. Exposure with this procedure is limited tothe immediatelymedial aspect of the talar dome, shoulder, and gutter.Although valgus stress may increase access to the dorsal aspect of thetalar dome, the maneuverability of equipment is severely limited bythe angle of the cut. Furthermore, the authors (13,14) suggest singlescrew fixation from the inferior tip of the medial malleolus orientedfrom distal medial to proximal lateral, which could lead to rotationalmalunion in the horizontal plane. Other authors (24,25) recommendan oblique osteotomy from superomedial to distal lateral beginningimmediately proximal to the plafond and angled toward the medial

corner of the ankle joint. This osteotomy was designed specificallyfor AO screw fixation. The oblique osteotomy has been translatedlaterally for access to central lesions. It is fixated with multiple screwsor a medial buttress plate (38). If the transverse or oblique osteotomyis cut below the joint level, the top of the talus will not be visiblebecause of sheltering by the contour of the tibial plafond. Becausethere is no inherent stability to either type of osteotomy, there is theadditional risk of rotation with placement of the fixation. With theoblique cut, there is an additional risk of proximal migration ofthe distal fragment leading to excessive shortening during screwplacement. Placing the first screw parallel to the plafond, therebystabilizing the fragment and the second screw perpendicular to theosteotomy, which will compress it, can prevent this. The fixation issimilar to open reduction and internal fixation of a supinationadduction II ankle fracture as described by Hamilton (39) and vanBergen et al (40), who found that shortening and rotation can beminimized if the malleolus is predrilled at 60� to the longitudinal axisof the tibia and the osteotomy is angled 30� relative to the tibial axisor perpendicular (90�) to the drill hole.

O’Farrell and Costello (26) described a shallow inverted chevron orV-osteotomy predrilled for AO fixation. Like the other approaches,incomplete visualization of the talus can occur, especially if theosteotomy falls below the joint line. Extensive dorsiflexion and plan-tarflexion are required for adequate visualization. If the osteotomy isperformed above the joint line, then completion of the osteotomy canbe quite arduous. Attaining equal opposition and compression duringfixation can also be difficult and can lead to excessive shifting andshortening.

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Wallen and Fallat (27) suggest a crescentic osteotomy using a largecrescentic oscillating blade and advocate tension band wiring forfixation. The osteotomy is cut proximal to or at the arch of the tibio-talar joint and the cut is contoured to the head of the talus. They alsostate that although the exposure is optimal, shortening will occurbecause of the width of the cut. Crescentic blades are also noted togenerate more heat that can lead to excessive thermal necrosis at theosteotomy site, which carries the additional risks of shortening anddelayed union. Tilting of the distal fragment was also stated asa potential complication.

Oznur (28) proposed a medial malleolar window or invertedU-osteotomy. The malleolus is predrilled for screw fixation beforea U-shaped cut (with the opening facing distally) is made. Once thefragment is loosened it is retracted inferiorly on the deltoid ligament,and an intra-articular procedure can be performed after sufficientdistraction. The dimensions of the U are determined by the size ofthe lesion, which is evaluated preoperatively with sagittal MRI orreconstructed CAT. Although the U-osteotomy may afford greatervisualization than the V-osteotomy, there appears to be an increasedrisk of iatrogenic complications because it involves a third cut in thebone. Like the V-osteotomy this procedure appears limited in its scopeto small lesions and relies on ankle range of motion for properintraoperative visualization.

The step-cut transmalleolar osteotomy was first described byAlexander and Watson (16). It creates a right-angled intersectingosteotomy 1.5 cm above the superomedial corner of the ankle joint.The distal fragment is predrilled as in the other procedures. Thegeometry of the osteotomy prevents proximal migration of the distalfragment unlike the oblique osteotomy. It also resists sagittal planetilting and horizontal plane rotation unlike the crescentic, chevron,malleolar window, and transverse osteotomies. All osteotomyconfigurations will cause some degree of shortening and all have thepotential to damage the articular cartilage of the talar dome, leadingto an expanding area of avascular necrosis, arthrosis, or tibial delayedunion. However, in the step-cut transmalleolar osteotomy, an osteo-tome is used to create the vertical cut at the axilla of the tibial plafondand, as a result, decreases the risk of iatrogenic talar dome damagewhen compared with the other osteotomy procedures.

In the senior author’s experience, posterior mobilization of theposterior tibial tendon is an essential part of this procedure bothto protect the tendon and to allow the distal fragment to be easilyretracted inferiorly. This view is also expressed by Thorsdarson andKaku (18) in their 2006 article. However, incising the entire retinac-ulum runs the risk of tendon dislocation (41).

When creating the vertical cut, it is very important that the intra-articular K-wire is held securely in place by the assistant in thesuperomedial corner of the ankle joint and that the osteotomeremains parallel to the K-wire. This will ensure that the joint will beentered in the non–weight-bearing portion of the plafond, mini-mizing the risks of arthritis. As described in the second case study,lateral placement of the vertical arm of the osteotomy will allowaccess to central lesions as well as orthogonal placement of intra-articular instrumentation (Fig. 15). It can also be used when treatingcentral lesions or when bulk talar allografts are going to be used.Despite the obvious advantages, a lateralized vertical cut it carrieswith it the risk of additional articular damage and iatrogenicarthrofibrosis.

Lee et al (17) suggest a modification of the step-cut procedurefor greater access to lesions that extend more centrally. Like thetraditional procedure, the apex of the osteotomy is located approxi-mately 1.5 cm above the axilla of the medial tibial plafond, but ratherthan perform the first cut of the osteotomy in the transverse plane,they angulate the saggital saw at a 45� angle and cut from proximal-medial to distal-lateral. They found that this modification allowed for

greater perpendicular access to the medial talar dome as wellas access to central lesions without sacrificing the stability of thetraditional step-cut procedure. Varner and Kolstad (41) found thatduring autologous osteochondral transplantation it was better tocreate the vertical limb before the horizontal limb because ofa tendency to fracture the posterior portion of the tibia, leavinga larger-than-desired segment. Varner and Kolstad, like Lee et al,suggest an obliquity to the horizontal cut to allow more access tomedial talar dome for instrumentation and transplantation.

Although Alexander and Watson (16) include it in their descrip-tion, this procedure requires very little subcutaneous dissection andperiosteal stripping which, combined with the broad cancelloussurface area and rigid AO fixation, allows for rapid healing in 4 to6 weeks. Early active range-of-motion exercises can be initiatedimmediately with minimal risk of malleolar displacement.

Like all surgeries, the step-cut medial malleolar osteotomy has thepotential for complications. It involves cutting a greater surface areaof bone than the other osteotomies and could potentially lead toa greater risk of malunion or nonunion than the smaller osteotomies.Overzealous incision or retraction of the tibialis posterior tendoncould lead to tendon dislocation or tendonitis. Improper incisionplacement or overzealous retraction could lead to injury of thesaphenous nerve and/or vein. Because of the subcutaneous locationand dynamic nature of the malleolus, irritation from the hardware isa likely complication.

In conclusion, because of anatomic constraints, many podiatric andorthopedic surgeons recommend an osteotomy of the medialmalleolus to gain access to the posteromedial ankle joint region. Acomprehensive literature review of approaches previously used togain access to the posteromedial ankle joint region and a descriptionof the step-cut medial malleolar osteotomy as described by Alexanderand Watson (16) were provided. The step-cut approach is technicallysimple to perform. It can be safely modified when treating centrallesions. It provides inherent osseous stability that minimizes risks ofdisplacement during rehabilitation. Additionally, it has a broadcancellous surface area, which facilitates osseous union. The authorsrecommend this procedure when an osteotomy is needed to gainaccess to the posteromedial ankle joint region.

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