AMERICAN ORTHOPAEDIC FOOT & ANKLE SOCIETY
June 2015
Radiographic Assessment of Lower Extremity
Alignment in Ankle Arthritis Using Long-Leg
Alignment Views
Benjamin R. Williams, MD1
James Holmes, MD1
Paul T. Fortin, MD2
Todd A Irwin, MD1
1
University of Michigan Health System, Department of Orthopaedic Surgery
2 William Beaumont Health System, Department of Orthopaedic Surgery
NO CONFLICT TO DISCLOSE
Radiographic Assessment of Lower Extremity Alignment
in Ankle Arthritis Using Long-Leg Alignment Views
Benjamin R. Williams
My disclosure is in the Final AOFAS Mobile App.
I have no potential conflicts with this presentation.
Ankle Arthritis



Ankle arthritis has been reported to be as physically
and mentally disabling as hip arthritis
70% of ankle arthritis cases are reported to be posttraumatic
Lower extremity deformities are common

These deformities, whether proximal or distal to the
knee and whether post-traumatic or otherwise, have an
effect on the biomechanical load at the ankle joint
Long-Leg Alignment



Long leg alignment views are currently used in
knee and hip surgeries to assess multilevel
angular deformities
In knee arthroplasty, restoring mechanical
alignment of the knee is critical for a successful
joint replacement
Radiographs of the ankle capture deformities at
the ankle and distal tibia, but will miss a
deformity present in the more proximal aspects
of the lower extremity
Purpose of Study

To use the long-leg alignment view in conjunction with standard
ankle radiographs to evaluate the presence of lower extremity
deformity in the setting of ankle arthritis



The presence of these deformities may have significant impact on surgical
decision-making in this cohort of patients
Investigate the mean axis deviation (MAD) at the knee through a
long-leg alignment view and determine if there is a correlation to the
degree of ankle arthritis
Determine the prevalence, specific location and characteristics of
lower extremity deformity in patients who present with ankle
arthritis
Outcome Assessment


Radiographic Measurements for affected and unaffected sides
 Mean axis of deviation (MAD) at the knee
 Anatomic medial proximal tibial angle (aMPTA)
 Anatomic lateral distal tibial angle (aLDTA)
 Joint line congruence angle (JLCA) at the knee
Arthritis Classification Scales

Knee


Kellgren-Lawrence
Ankle



Takakura
van Dijk
COFAS
MAD
JLCA
aMPTA
aLDTA
Results

53 patients (59 arthritic ankles) without prior ankle surgery



Mean age 59 years (range, 28 to 85 years)
24 left and 35 right ankles
15 female patients and 38 male patients
Patient’s grouped by Arthritis Grades
Van Dijk
Grade
0
0
Takakura
X
COFAS
1 (2%)
Kellgren-Lawrence
(knee)
2 (4%)
Grade 1 Grade 2 Grade 3 Grade 3a Grade
Grade 4
3b
0
X
X
X
13
46
(22%)
(78%)
0
2 (3%)
X
4 (7%) 26 (44%)
27
(46%)
9 (15%) 4 (7%)
X
X
10
35
(17%)
(59%)
11 (20%)
X
X
2 (4%)
17
22
(31%)
(41%)
Results cont.





47 patients had unilateral ankle arthritis
When compared to the contralateral, unaffected ankle:
 57.4% of patients had a change in MAD (Δ MAD) ≥10 mm
 25.5% of patients had a Δ JLCA ≥ 3°
 19.1% of patients had a Δ aMPTA ≥ 5°
 48.9% of patients had a Δ aLDTA ≥ 5°
A higher aLDTA was a significant predictor for allocation to a grade 3 van
Dijk ankle arthritis grade
No predictive effect was found between the proximal radiographic
parameters and degree of ankle arthritis
A Kellgren-Lawrence knee arthritis grade increase from 2 to 3 correlated
with an increase in van Dijk ankle arthritis grade from 2 to 3
Case example
The clinical utility of the LLA is demonstrated by this patient
•The ankle radiograph demonstrated ankle arthritis without
visualizing more proximal deformity
•The LLA view shows a genu varus deformity which likely
contributes to the patients compensatory valgus ankle arthritis.
•Angular measurements indicate a varus aMPTA, suggesting a
proximal tibia osteotomy may be needed to correct overall
alignment.
Conclusions



In patients with ankle arthritis, there is a high prevalence
of lower extremity malalignment using radiographic
parameters measured with a LLA view when compared
to the unaffected extremity
While proximal malalignment was not found to be
predictive of degree of ankle arthritis, it is important to
recognize the presence of these deformities when surgical
planning is performed
We recommend obtaining LLA view in all patients with
ankle arthritis, in particular those who will undergo a
total ankle arthroplasty
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