Contraindication to supramalleolar osteotomy?

• A. Talar tilt >10 degrees
• B. Posterior tibial tendon dysfunction
• C. Degenerative changes at subtalar joint
• D. Normal ankle ROM

Answer: (A)

A key idea in selecting patients for a supramalleolar osteotomy is that the procedure works best when the ankle joint itself is the primary source of deformity and the joint surfaces are still relatively congruent. A talar tilt greater than about 10 degrees shows that the talus is tilted within the ankle mortise, which usually means there is a significant hindfoot or subtalar contribution to the deformity. In this situation, simply realigning the distal tibia won’t fully correct the abnormal joint mechanics, and the result of the osteotomy would be unreliable with persistent incongruence and abnormal load distribution. That’s why a talar tilt over10 degrees is considered a contraindication.

The other factors you listed aren’t absolute turnoffs. Posterior tibial tendon dysfunction reflects hindfoot dysfunction that may complicate outcomes and often requires addressing hindfoot mechanics as well, but it isn’t an automatic disqualifier for an ankle-focused correction in all cases. Degenerative changes at the subtalar joint are also a relative concern rather than an outright contraindication, depending on severity and symptoms, because some patients may still benefit from realignment if the ankle joint is otherwise well-preserved. Normal ankle range of motion is a favorable finding, indicating good soft-tissue versatility and joint potential, which supports proceeding with this procedure.