{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T22:10:05Z","timestamp":1787695805122,"version":"build-2784847793"},"reference-count":46,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2026,2,17]],"date-time":"2026-02-17T00:00:00Z","timestamp":1771286400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Medial opening-wedge supramalleolar osteotomy (MOWSMO) is a joint-preserving surgical option for varus ankle osteoarthritis (OA); however, its ability to correct large varus talar tilt (TT), particularly in advanced diseases like Takakura stage IIIB, remains limited. Varus TT represents a complex three-dimensional deformity characterized by coronal malalignment and internal rotation, which cannot be reliably corrected by isolated supramalleolar realignment. Building on our previous work, we propose a new treatment algorithm for large varus TT based on preoperative tibial plafond inclination (TPI) and arthritis type, categorized as translational and rotational. While MOWSMO primarily addresses TPI, effective correction of talar inclination requires a balanced, multilevel approach. This includes using an oblique sliding fibular osteotomy to facilitate rotational realignment with fibular shortening and, critically, prioritizing inframalleolar correction (IMC). IMC is implemented through an \u201call-in-one\u201d strategy involving lateral ligament repair, deltoid ligament release, calcaneal osteotomy, and posterior tibial tendon lengthening. Furthermore, we discuss critical intraoperative considerations, such as avoiding excessive TPI valgization to prevent a \u201cparadoxical increase\u201d in TT. Collectively, this framework provides clinically relevant insights and a reproducible algorithm for achieving satisfactory outcomes in the joint-preserving management of severe varus ankle OA.<\/jats:p>","DOI":"10.3390\/jcm15041580","type":"journal-article","created":{"date-parts":[[2026,2,17]],"date-time":"2026-02-17T13:15:35Z","timestamp":1771334135000},"page":"1580","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Surgical Correction of Large Talar Tilt in Varus Ankle Osteoarthritis II: A New Treatment Algorithm Based on the Tibial Plafond Inclination and Arthritis Types"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3864-9521","authenticated-orcid":false,"given":"Jun Young","family":"Choi","sequence":"first","affiliation":[{"name":"Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang 10380, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jin Soo","family":"Suh","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang 10380, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,2,17]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"50","DOI":"10.1302\/0301-620X.77B1.7822395","article-title":"Low tibial osteotomy for osteoarthritis of the ankle. Results of a new operation in 18 patients","volume":"77","author":"Takakura","year":"1995","journal-title":"J. Bone Jt. Surg. Br."},{"key":"ref_2","first-page":"44","article-title":"Epidemiology of ankle arthritis: Report of a consecutive series of 639 patients from a tertiary orthopaedic center","volume":"25","author":"Saltzman","year":"2005","journal-title":"Iowa Orthop. J."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"545","DOI":"10.1016\/j.fcl.2012.08.003","article-title":"The concept of ankle joint preserving surgery: Why does supramalleolar osteotomy work and how to decide when to do an osteotomy or joint replacement","volume":"17","author":"Tanaka","year":"2012","journal-title":"Foot Ankle Clin."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"909","DOI":"10.1302\/0301-620X.88B7.17325","article-title":"Low tibial osteotomy for varus-type osteoarthritis of the ankle","volume":"88","author":"Tanaka","year":"2006","journal-title":"J. Bone Jt. Surg. Br."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1016\/j.fcl.2021.11.002","article-title":"Joint preservation strategies for managing varus ankle deformities","volume":"27","author":"Hintermann","year":"2022","journal-title":"Foot Ankle Clin."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"5549","DOI":"10.1007\/s00402-023-04867-1","article-title":"Supramalleolar osteotomies for ankle arthritis: A systematic review","volume":"143","author":"Christidis","year":"2023","journal-title":"Arch. Orthop. Trauma Surg."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Alajlan, A., Santini, S., Alsayel, F., Teoh, K.H., Alharbi, W., Puls, L., Camathias, C., Herrera-P\u00e9rez, M., Tejero, S., and Barg, A. (2022). Joint-Preserving Surgery in Varus Ankle Osteoarthritis. J. Clin. Med., 11.","DOI":"10.3390\/jcm11082194"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1139","DOI":"10.1016\/j.fas.2022.06.002","article-title":"Is there an optimal degree of correction for ankle varus deformity after supramalleolar osteotomy? A systematic review","volume":"28","author":"Beijk","year":"2022","journal-title":"Foot Ankle Surg."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Xue, W., Chen, T., Wahafu, P., Li, F., Xiahatai, A., Wufuer, A., Tuo, Y., Zhao, B., and Wang, C. (2022). Efficacy evaluation and systematic review of supramalleolar osteotomy for treatment of varus-type ankle arthritis. J. Orthop. Surg., 30.","DOI":"10.1177\/10225536221122286"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1243","DOI":"10.2106\/JBJS.J.00249","article-title":"Indications for supramalleolar osteotomy in patients with ankle osteoarthritis and varus deformity","volume":"93","author":"Lee","year":"2011","journal-title":"J. Bone Jt. Surg. Am."},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Choi, J.Y., Kim, J.H., Kim, B.G., and Suh, J.S. (2025). Critical factors in enhancing the correction efficacy for varus talar tilt in patients with varus ankle osteoarthritis: Relative fibular shortening to the tibia and syndesmotic widening. Arch. Orthop. Trauma Surg., 145.","DOI":"10.1007\/s00402-025-05761-8"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"507","DOI":"10.2106\/00004623-197153030-00007","article-title":"The weight-bearing function of the fibula. A strain gauge study","volume":"53","author":"Lambert","year":"1971","journal-title":"J. Bone Jt. Surg. Am."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1232","DOI":"10.1302\/0301-620X.93B9.25759","article-title":"The role of the fibula in varus and valgus deformity of the tibia: A biomechanical study","volume":"93","author":"Stufkens","year":"2011","journal-title":"J. Bone Jt. Surg. Br."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1809","DOI":"10.2106\/00004623-199712000-00006","article-title":"The effect of fibular malreduction on contact pressures in an ankle fracture malunion model","volume":"79","author":"Thordarson","year":"1997","journal-title":"J. Bone Jt. Surg. Am."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"261","DOI":"10.1097\/00003086-199609000-00034","article-title":"Fibula and its ligaments in load transmission and ankle joint stability","volume":"330","author":"Wang","year":"1996","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1071","DOI":"10.1007\/s00256-017-2655-0","article-title":"Weight-bearing computed tomography findings in varus ankle osteoarthritis: Abnormal internal rotation of the talus in the axial plane","volume":"46","author":"Kim","year":"2017","journal-title":"Skelet. Radiol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"217","DOI":"10.1016\/j.fas.2020.04.006","article-title":"Perioperative axial loading computed tomography findings in varus ankle osteoarthritis: Effect of supramalleolar osteotomy on abnormal internal rotation of the talus","volume":"27","author":"Song","year":"2021","journal-title":"Foot Ankle Surg."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Choi, J.Y., and Suh, J.S. (2025). Surgical correction of large talar tilt in varus ankle osteoarthritis: Lessons from clinical experience and a review of the literature. J. Clin. Med., 14.","DOI":"10.3390\/jcm14082781"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"975","DOI":"10.1007\/s00167-020-06060-y","article-title":"Hip-to-calcaneus alignment differs from hip-to-talus alignment in patients with genu varum deformity","volume":"29","author":"Kim","year":"2021","journal-title":"Knee Surg. Sports Traumatol. Arthrosc."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"333","DOI":"10.2106\/JBJS.M.01327","article-title":"Weight-bearing-line analysis in supramalleolar osteotomy for varus-type osteoarthritis of the ankle","volume":"97","author":"Haraguchi","year":"2015","journal-title":"J. Bone Jt. Surg. Am."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"572","DOI":"10.1177\/107110079501600911","article-title":"The hindfoot alignment view","volume":"16","author":"Saltzman","year":"1995","journal-title":"Foot Ankle Int."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"366","DOI":"10.1016\/j.fas.2020.04.010","article-title":"Radiographic measurements on hindfoot alignment view in 1128 asymptomatic subjects","volume":"27","author":"Choi","year":"2021","journal-title":"Foot Ankle Surg."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Choi, W., Chung, C.Y., Park, M.S., Lee, S., and Lee, K.M. (2021). Radiographic differences in the concomitant deformities in two types of medial ankle osteoarthritis. PLoS ONE, 16.","DOI":"10.1371\/journal.pone.0247816"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"542","DOI":"10.3113\/FAI.2007.0542","article-title":"Supramalleolar lateral closing wedge osteotomy for the treatment of varus ankle arthrosis","volume":"28","author":"Harstall","year":"2007","journal-title":"Foot Ankle Int."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"474","DOI":"10.1177\/10711007211050639","article-title":"Dome supramalleolar osteotomies for the treatment of ankle pain with opposing coronal plane deformities between ankle and the lower limb","volume":"43","author":"Kim","year":"2022","journal-title":"Foot Ankle Int."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"791","DOI":"10.1007\/s00402-021-04164-9","article-title":"Correction of ankle varus deformity using patient-specific dome-shaped osteotomy guides designed on weight-bearing CT: A pilot study","volume":"143","author":"Faict","year":"2023","journal-title":"Arch. Orthop. Trauma Surg."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1122","DOI":"10.1177\/1071100720938801","article-title":"Low tibial valgization osteotomy for more severe varus ankle arthritis","volume":"41","author":"Choi","year":"2020","journal-title":"Foot Ankle Int."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"211","DOI":"10.1177\/10711007211035784","article-title":"Radiographic outcomes of proximal vs. distal syndesmotic low tibial osteotomy","volume":"43","author":"Choi","year":"2022","journal-title":"Foot Ankle Int."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1379","DOI":"10.1007\/s00402-021-04301-4","article-title":"Value of postoperative computed tomography for the diagnosis of lateral hinge fracture in medial opening-wedge supramalleolar osteotomy","volume":"143","author":"Park","year":"2023","journal-title":"Arch. Orthop. Trauma Surg."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1097\/BTO.0000000000000643","article-title":"Protective Kirschner wire fixation to reduce the effect of lateral hinge fracture during the medial opening wedge low tibial osteotomy: A technical note","volume":"39","author":"Choi","year":"2024","journal-title":"Tech. Orthop."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"2013","DOI":"10.1007\/s00264-023-05822-w","article-title":"Evaluation of clinico-radiological outcome of fibular valgization osteotomy with supra-malleolar osteotomy in patients with ankle osteoarthritis","volume":"47","author":"Lim","year":"2023","journal-title":"Int. Orthop."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1053\/j.jfas.2016.08.003","article-title":"Effect of Combined Fibular Osteotomy on the Pressure of the Tibiotalar and Talofibular Joints in Supramalleolar Osteotomy of the Ankle: A Cadaveric Study","volume":"56","author":"Choi","year":"2017","journal-title":"J. Foot Ankle Surg."},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Liang, J.Q., Wang, J.H., Zhang, Y., Wen, X.D., Liu, P.L., Liang, X.J., Lu, J., Li, Y., and Zhao, H.M. (2021). Fibular osteotomy is helpful for talar reduction in the treatment of varus ankle osteoarthritis with supramalleolar osteotomy. J. Orthop. Surg. Res., 16.","DOI":"10.1186\/s13018-021-02732-8"},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Zhao, H., Liang, X., Li, Y., Yu, G., Niu, W., and Zhang, Y. (2016). The role of fibular for supramalleolar osteotomy in treatment of varus ankle arthritis: A biomechanical and clinical study. J. Orthop. Surg. Res., 11.","DOI":"10.1186\/s13018-016-0462-2"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"443","DOI":"10.1016\/j.fcl.2008.04.008","article-title":"Valgus ankle deformity and arthritis","volume":"13","author":"Bluman","year":"2008","journal-title":"Foot Ankle Clin."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1282","DOI":"10.1177\/10711007251372142","article-title":"Oblique sliding fibular osteotomy as an adjunct to supramalleolar osteotomy in varus ankle osteoarthritis: Comparative radiographic and clinical outcomes","volume":"46","author":"Choi","year":"2025","journal-title":"Foot Ankle Int."},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Choi, J.Y., and Suh, J.S. (2024). Joint preserving procedures for Takakura stage IIIB varus ankle osteoarthritis. BMJ Case Rep., 17.","DOI":"10.1136\/bcr-2024-260585"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"475","DOI":"10.3113\/FAI.2009.0475","article-title":"Ligament reconstruction and calcaneal osteotomy for osteoarthritis of the ankle","volume":"30","author":"Lee","year":"2009","journal-title":"Foot Ankle Int."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1554","DOI":"10.1177\/10711007211027290","article-title":"Joint preservation surgery for varus ankle arthritis with large talar tilt","volume":"42","author":"Park","year":"2021","journal-title":"Foot Ankle Int."},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Park, C.H., Park, J.J., and Woo, I.H. (2024). Joint preservation surgery using supramalleolar osteotomy combined with posterior tibial tendon release and lateral ligament augmentation in advanced varus ankle arthritis. J. Clin. Med., 13.","DOI":"10.3390\/jcm13164803"},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Qu, W., Xin, D., Dong, S., Li, W., and Zheng, Y. (2019). Supramalleolar osteotomy combined with lateral ligament reconstruction and talofibular immobilization for varus ankle osteoarthritis with excessive talar tilt angle. J. Orthop. Surg. Res., 14.","DOI":"10.1186\/s13018-019-1457-6"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"203","DOI":"10.1177\/10711007211036699","article-title":"Repositional subtalar arthrodesis combined with supramalleolar osteotomy for late-stage varus ankle arthritis with hindfoot valgus","volume":"43","author":"Park","year":"2022","journal-title":"Foot Ankle Int."},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Choi, J.Y., and Suh, J.S. (2022). Effect of four combined procedures to achieve inframalleolar correction for advanced varus ankle arthritis. BMJ Case Rep., 15.","DOI":"10.1136\/bcr-2022-249197"},{"key":"ref_44","doi-asserted-by":"crossref","unstructured":"Kyung, M.G., Cho, Y.J., Lee, J., Lee, W., Kim, D.Y., Lee, D.O., and Lee, D.Y. (2021). Relationship between talofibular impingement and increased talar tilt in incongruent varus ankle osteoarthritis. J. Orthop. Surg., 29.","DOI":"10.1177\/23094990211045219"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"80","DOI":"10.1302\/0301-620X.41B1.80","article-title":"Osteotomy of the calcaneum for pes cavus","volume":"41-B","author":"Dwyer","year":"1959","journal-title":"J. Bone Jt. Surg. Br."},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Willegger, M., Seyidova, N., Schuh, R., Windhager, R., and Hirtler, L. (2020). The tibialis posterior tendon footprint: An anatomical dissection study. J. Foot Ankle Res., 13.","DOI":"10.1186\/s13047-020-00392-1"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/4\/1580\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,17]],"date-time":"2026-02-17T13:26:38Z","timestamp":1771334798000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/4\/1580"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2,17]]},"references-count":46,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2026,2]]}},"alternative-id":["jcm15041580"],"URL":"https:\/\/doi.org\/10.3390\/jcm15041580","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,17]]}}}