Purpose of the study: Frequently described in pediatric orthopedics, supramalleolar osteotomies are theoretically logical in adults, but relatively little studied.

Material and methods: Supramalleolar osteotomy was performed for misaligned callus formation or secondary osteoarthrtitis of the ankle joint in fourteen patients in our institution since 1987. Among these fourteen patients, nine were reviewed, of which three underwent surgery for misaligned callus of the distal third of the tibia measuring more than six degrees and asymptomatic at the time of surgery. The six other patients suffered pain with associated tibiotalar osteoarthritis for four. These six patients also underwent surgery. The nine patients were reviewed clinically and radiographially.

Results: Mean follow-up was 53 months (range 6–202 months). Mean time to bone healing measured radiographically was 12.2 weeks (range 9–18 weeks). The difference in time to healing between closed and open wedge osteotomies was not significant (p=0.1, Student’s test). The difference in the preoperative AOFAS score compared with the last follow-up score was statistically significant (p=0.01) with an improvement in the AOFAS pain score (p=0.03). Function scores of open and closed wedge osteotomies were not statistically different (p=0.5). In the four patients who presented ankle osteoarthritis at the time of surgery, there was no postoperative progression of the joint degradation. Conversely, in two patients whose joint was free of signs of osteoarthritis at the time of surgery, stage I signs appeared. These two patients were reviewed at 46 and 202 months respectively from the osteotomy which in both cases had been performed to prevent the supposedly deleterious effect of a distal tibial callus misaligned 10°.

Conclusion: Open and closed wedge supramalleolar osteotomies are the preferred procedure for distal tibial callus misalignment measuring more than 10° with the reservation that the underlying joints are sufficiently mobile, the advantage of osteotomy over arthrodesis being closely related to this factor. Arthrodesis might however be considered if joint pain predominates the clinical picture.

Purpose: Dwyer osteotomy remains controversial as shown by the numerous series reported. Conclusions have varied and there is no real consensus. The cause of these divergent opinions is related to the variability of indications (association or not with active neurological disease) and surgical schools. Interpretation of outcome and comparisons are hindered.

Material and methods: We reviewed 22 cases of Dwyer osteotomy of the calcaneum performed between 1972 and 2002. The lateral approach was used for closed osteotomy. Mean follow-up was ten years (1–30). Patients were aged 8 to 55 years. The objective and subjective rating system of Laaveg and Panseti (1980) was used. Indications were: neurological pes cavus (n=13) including five unilateral and four bilateral cases, pes equinovarus sequela of clubfoot (n=n=2), idiopathic varus of the hindfood with ankle instability (n=5), posttraumatic varus sequela of a compartment syndrome (n=2).

Discussion: Dwyer osteotomy is rarely performed alone and is frequently associated with other interventions (tendon lengthening and transfer, forefoot procedure, toe procedure) making it difficult to interpret results. Our study was not designed to draw definitive conclusion but rather to compare our indications and results with earlier reports.

Conclusion: Dwyer osteotomy performed with a rigorous technique appears to be an effective means for correcting constitutional varus. The site of the osteotomy and bone resection are particularly important. There are few complications. Bone healing is generally achieved. The procedure is an excellent solution for patients with associated ankle instability because it provides an easy and effective way to correct moderate varus. It is also a good solution for revision of clubfoot when aponeurotic and tendon release is also indicated. Results are insufficient for neurological pes cavus when there is residual or active tendon imbalance. It can however be a temporary solution in the young patient who will undergo arthrodesis later.

Two neonates, treated by the Pavlik harness for congenital dislocation of the hip, developed inferior dislocation due to excessive hip flexion. Early recognition of the complication and diminution of the angle of flexion gave a stable relocation of the hip in both patients.