Clin Podiatr Med Surg

21 (2004) 305 326

Deformity correction planning for hindfoot,

ankle, and lower limb
Bradley M. Lamm, DPM, Dror Paley, MD*
Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue,
Baltimore, MD 21215, USA

Many patients with hindfoot, ankle, and lower limb pathologic abnormalities
have concurrent osseous and soft tissue deformities. Lower extremity deformities
are congenital, dysplastic, developmental, or traumatic in origin. Corrective surgery can best be planned with a sound understanding of limb deformity principles. The principles clearly define accurate reference points for producing
predictable results. These geometrically based principles originate from a
standard set of radiographic angles and reference points (Fig. 1) [1]. Deformity
correction requires extensive surgical experience and knowledge of the principles presented in this article.

Clinical and radiographic evaluation of deformity

In addition to pertinent medical and surgical histories, a detailed history of the
cause and resultant effects of the deformity should be elicited. Performing a
thorough physical examination to include observing patients during gait and
stance is very important.
It has been well documented that an understanding of radiographic angular
relationships is critical for appropriate evaluation and identification of the level and
extent of deformity [1]. Obtaining accurate radiographs is essential for surgical
planning. Erect lower limb radiographs (full lower extremity, including pelvis,
femur, tibia, fibula, and foot) and long lateral view radiographs are important for
measuring overall lower extremity alignment, joint orientation angles, and limb
length discrepancies. They also are essential for locating the center of rotation of

* Corresponding author.
E-mail address: dpaley@lifebridgehealth.org (D. Paley).
0891-8422/04/$ see front matter D 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cpm.2004.04.004

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Anatomic

B
MNSA = 130
(124136)

Sagittal

PPFA = 90

ANSA = 170
(165175)

MPFA = 84
(8089)

aLDFA = 81
(7983)

PDFA = 83
(7987)

JLCA
(02)
MPTA = 87
(8590)

LDTA = 89
(8692)

PPTA = 81
(7784)

ADTA = 80
(7882)

Fig. 1. (A) Normal joint orientation angles and nomenclature in the frontal plane, as referenced by the
anatomic axis. (B) Normal joint orientation angles and nomenclature in the sagittal plane, as
referenced by the anatomic axis. (From Paley D. Principles of deformity correction. Berlin: SpringerVerlag; 2003.)

angulation (CORA), or apex, of the deformity (Fig. 2) [1]. These long radiographs
should be obtained even when deformity is isolated to the foot and ankle.
It is important to obtain routine weight-bearing anteroposterior and lateral
view radiographs of the foot and ankle; however, frontal plane alignment of the
hindfoot is not well visualized on these views. Harris and Beath [2] described a
frontal plane radiograph of the heel, which was later modified by Kleiger and
Mankin (posterior tangential view) into what is now known as a long calcaneal
axial view [3]. A long calcaneal axial view radiograph shows the relationship of
the calcaneus to the leg and the subtalar joint (Fig. 3). Another frontal plane
technique was described by Cobey [4] in 1976 and was later modified by
Saltzman and el-Khoury [5]. This hindfoot alignment (Saltzman) view allows
visualization of the ankle joint together with the relationship of the body of the
calcaneus to the tibia (Fig. 4) [1,4,5]. These frontal plane radiographs provide
essential information regarding the calcaneal-tibial relationship (Fig. 5).

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307

Fig. 2. Images from the case of a 13-year-old boy with ankle pain occurring 3 years after ankle
fracture. (A) No identifiable pathologic abnormality can be seen on the anteroposterior view
radiograph of the ankle. (B) However, the erect full lower extremity radiograph shows that the MAD is
medial to the center of the knee on the affected side. This implies that a varus deformity is located
somewhere within the femur or tibia. (C) After systematically measuring the limb deformity axis and
joint orientation lines, we observed that the CORA was located in the proximal tibia. This patient had
proximal tibial varus and limb length discrepancy. Without the erect full lower extremity radiograph
and appropriate limb deformity planning, an accurate diagnosis likely would not have been attained.

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A.

B.

45

45

(17 in or
43 cm)

(17 in or
43 cm)

Fig. 3. (A) Long calcaneal axial view radiograph can be obtained with the patient in a non weightbearing or supine position, such as on the operating room table. The foot is at 90 degrees to the leg
while the x-ray beam is angled at 45 degrees to the cassette. The cassette should be large enough to
include the entire calcaneus and the distal half of the tibia. The x-ray beam should be in line with the
calcaneus. (B) Long calcaneal axial view radiograph can be obtained with the patient in a weightbearing or standing position, such as during stance. The same technique as that described for panel
(A) is used. (From Paley D. Principles of deformity correction. Berlin: Springer-Verlag; 2003.)

20

20

Fig. 4. Hindfoot alignment (Saltzman) view is obtained with the patient standing on a radiolucent box
or platform with the cassette angled 20 degrees (see illustration). The x-ray beam is adjusted to be
perpendicular to the cassette. The cassette should be large enough to include the entire calcaneus
and the distal half of the tibia. (From Paley D. Principles of deformity correction. Berlin: SpringerVerlag; 2003.)

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309

Fig. 5. A, Long calcaneal axial view radiograph allows visualization of the subtalar joint and the
relationship of the calcaneus to the tibia. This radiograph is also useful for assessing the tuber of
the calcaneus. B, Hindfoot alignment (Saltzman) view allows visualization of the ankle joint and the
relationship of the calcaneus to the tibia. This radiograph is also useful for assessing the amount of
lateral translation of the calcaneus. The combination of these two radiographs is valuable for hindfoot
and ankle deformity planning. (From Paley D. Principles of deformity correction. Berlin: SpringerVerlag; 2003.)

To assess the position of the foot during gait, the radiographs should be
obtained with the patient bearing weight. A mortise lateral view radiograph is
important for accurate measurement and visualization of the tibial plafond, talar
dome, and anterior ankle osteophytes (Fig. 6). Stress radiographs also are
important to differentiate soft tissue abnormalities from osseous deformities.
Maximum ankle dorsiflexion radiographs aid in assessment of equinus versus
osseous anterior ankle impingement. Real-time fluoroscopy adds a fourth dimension to the evaluation of ankle, subtalar joint, and midfoot motion [1].

Definitions
The mechanical axis of the lower extremity is the line from the center of the
femoral head to the center of the ankle plafond. Mechanical axis deviation
(MAD) is the perpendicular distance from the mechanical axis of the lower
extremity line to the center of the knee joint (Fig. 7). The mechanical axis of the
tibia is the line from the center of the knee joint to the center of the ankle plafond
(Fig. 8). The anatomic axis of the tibia is the mid-diaphyseal line of the tibia
(Fig. 9). A joint orientation angle is the angle between the anatomic or me-

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Fig. 6. Lateral view radiographs are obtained with the foot placed against the cassette. Such
positioning produces a radiograph that lacks superimposition of the talar dome and tibial plafond. The
mortise lateral view radiograph of the ankle is obtained with the leg internally rotated by 15 degrees,
which displaces the heel slightly away from the cassette when positioning. With the mortise lateral
view radiograph of the ankle, the two malleoli are overlapped, the medial and lateral aspects of the
talar dome are superimposed, and the tibial plafond is seen in maximum profile. The mortise lateral
view radiograph provides ease for drawing joint orientation lines, thereby improving accuracy. It is
good to compare views that are orthogonal, such as the mortise anteroposterior and the mortise lateral
view radiographs (both are obtained with the leg in 15 degrees of internal rotation).

chanical axis of the bone and the joint line in either the frontal or sagittal plane.
Joint orientation angle nomenclature is presented in Fig. 1.

Tibia
The mechanical axis of the lower extremity typically passes through or just
medial to the center of the knee joint. The normal range of the MAD is 8 8 mm
medial (Fig. 7). The anatomic axis of the tibia usually passes though the medial
tibial spine. The tibial mechanical axis passes through the center of the knee and
ankle joints. The tibial anatomic axis is parallel but just medial to the mechanical
axis (Fig. 10). In the sagittal plane, the anatomic axis of the tibia (mid-diaphyseal
line) intersects the tibial plateau joint orientation line one-fifth from the anterior
surface of the tibia and crosses the center of the ankle.

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311

MAD
8 mm

Bhave et al., unpublished results 4.1 4 mm

Paley et al., 1994
9.7 6.8 mm

Fig. 7. MAD is the perpendicular distance between the mechanical axis of the lower extremity (center
of femoral head to center of ankle) and the center of the knee joint. The mechanical axis line normally
passes 8 mm medial to the center of the knee. (From Paley D. Principles of deformity correction.
Berlin: Springer-Verlag; 2003.)

In the frontal plane, the joint orientation angles are the medial proximal tibial
angle (MPTA), with a norm of 87.5 2.5 degrees, and the lateral distal tibial
angle (LDTA), with a norm of 89 3 degrees. In the sagittal plane, the joint
orientation angles are the posterior proximal tibial angle (PPTA), with a norm of
81 3 degrees, and the anterior distal tibial angle (ADTA), with a norm of 80
2 degrees (Fig. 1).
The ankle joint orientation is in slight valgus to the tibial shaft. In the frontal
plane, during the midstance phase of gait (single support time), the tibia is
orientated in 3 degrees of adduction, thereby allowing the tibial plateau to
become horizontal (87 degrees plus 3 degrees equals 90 degrees). Similarly, the
ankle joint slight valgus makes the ankle parallel to the knee joint and therefore
parallel to the ground during single leg stance. In the sagittal plane, during the
mid-stance phase of gait (maximum loading), the tibia is oriented 10 degrees

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Fig. 8. Mechanical axis line of the tibia is drawn between the center of the knee and ankle. (From
Paley D. Principles of deformity correction. Berlin: Springer-Verlag; 2003.)

Fig. 9. Anatomic axis line of the tibia is drawn as a mid-diaphyseal line of the tibia. (From Paley D.
Principles of deformity correction. Berlin: Springer-Verlag; 2003.)

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Mechanical
axis

313

Anatomic
axis

Fig. 10. Anatomic and mechanical axis lines of the tibia are parallel. (From Paley D. Principles of
deformity correction. Berlin: Springer-Verlag; 2003.)

inclined forward toward the ground (knee flexed 20 degrees), and the ankle is in
10 degrees of dorsiflexion. Therefore, the normally sloped tibial plateau and
tibial plafond become horizontal during maximum loading, distributing the forces
more evenly in an axial direction, which minimizes shear while maximizing the
surface area of joint contact.

Talus
The tibiotalar joint, or ankle joint, is congruent without joint line convergence
between the dome of the talus and the tibial plafond in the frontal plane. This is
unlike the knee joint. With the knee joint, an angle of up to 3 degrees (joint line
convergence angle [JLCA]) may exist normally between the tibial plateau and
femoral condyles. The shape of the talus in the frontal plane appears square in
cross-section. The anatomic axis of the tibia intersects the dome of the talus just
medial to the bisection (center) of the talar dome (Fig. 11). The relationship of the
malleoli to the tibia was described by Inman [6] as the talocrural angle, measuring
82 3.6 degrees (Fig. 12A). We prefer to measure the plafond malleolar angle

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Tibial diaphyseal lines

Mid-diaphyseal
line

Talus
width line

Talus
Mid-talus
width line
line

Fig. 11. Anatomic axis of the tibia falls slightly medial to the midline of the talus. The cortical lines of
the tibia fall within the body of the talus. (From Paley D. Principles of deformity correction. Berlin:
Springer-Verlag; 2003.)

because it is independent of any supramalleolar deformity. This angle normally

measures 9 4 degrees (Fig. 12B). The plafond malleolar angle is a measure of
the level of the lateral malleolus relative to the rest of the ankle joint [1].
In the sagittal plane, the talar projection appears circular in shape. Inman [6]
described the three-dimensional shape of the talus as a frustum (section of a cone)
and discovered that the ankle joint axis (center of rotation of the ankle joint) is not
parallel to the joint line in either the frontal or sagittal plane. The ankle joint axis
is best approximated as a line running from the tip of the lateral to the tip of the
medial malleolus. In the frontal plane, the ankle joint axis is oriented at the
talocrural angle. On a lateral view radiograph, the center of rotation of the ankle
joint is best approximated at the lateral process of the talus. The mid-diaphysial
line of the tibia on the lateral view coincides with the lateral process of the talus.
This is a critical reference point to consider when performing surgery to achieve
realignment of the hindfoot and ankle. The plantigrade angle is the angle between
the anatomic axis of the tibia, perpendicular to the floor, and the sole of the foot
when standing. The normal plantigrade angle is 90 degrees (Fig. 13).

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A.

315

B.

82 3.6
9 4

2030

Fig. 12. A, Ankle joint axis, or center of rotation of the ankle joint, passes beneath the tip of the
medial and lateral malleoli. The normal talocrural angle measures 82 degrees in the frontal plane, and
the transmalleolar axis measures 20 to 30 degrees externally rotated in the transverse plane. B, Plafond
malleolar angle measures the level of the lateral malleolus relative to the ankle joint. The normal
plafond malleolar angle is 9 degrees. The shape of the talar dome has been described as section of a
cone. (Modified with permission from Springer-Verlag [1]).

aADTA = 80

Fig. 13. Tibial mid-diaphysial line normally passes through the lateral process of the talus on a lateral
view radiograph. The lateral process of the talus approximately represents the center of rotation of the
ankle joint. The angle between the floor or plantar foot in stance and the anatomic axis of the tibia is
the plantigrade angle. The normal plantigrade angle is 90 degrees. (Reproduced with permission from
Springer-Verlag [1]).

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Calcaneus
The calcaneal relationship to the talus and tibia is important, especially in
frontal plane assessment. The bisection of the calcaneus is parallel to the
anatomic axis of the tibia. The center of the heel is approximately 5 to 10 mm
lateral to the anatomic axis of the tibia (Fig. 14). The hindfoot alignment
(Saltzman) radiograph allows for visualization of the ankle joint and relationship
of the calcaneus and tibia. This view also provides assessment of the lateral
translation of the calcaneus in relation to the tibia (10 mm). The long calcaneal
axial view radiograph allows visualization of the subtalar joint and shows the
positional relationship of the calcaneus and tibia. The shape of the calcaneus also
can be assessed for osseous varus. The posterior and middle facets of the subtalar
joint are stepped; the middle facet (sustentaculum tali) is more proximal and
medial. The lateral translation of the heel to the tibia is critical for normal gait and
locomotion. The ground reaction force vector (GRV) originates at the plantar
lateral portion of the foot and extends through the anterolateral aspect of the tibial
plafond (Fig. 15).
In the sagittal plane, the plantar aspect of calcaneus is inclined by approximately 20 to 30 degrees. Equinus is noted with a lower calcaneal pitch or with a
decreased calcaneal inclination angle. The calcaneus is observed with a higher
calcaneal pitch or an increased calcaneal inclination [7]. It also is important to

Mid-diaphyseal

Body
weight
Mid-calcaneus

Floor
contact
Fig. 14. Center of the calcaneus is normally 10 mm lateral to the anatomic axis of the tibia. (From
Paley D. Principles of deformity correction. Berlin: Springer-Verlag; 2003.)

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317

Fig. 15. GRV originates from the plantar lateral midfoot and passes anterior and lateral to the center
of the ankle joint. The GRV also passes medial to the knee toward the 10th thoracic vertebra. (From
Paley D. Principles of deformity correction. Berlin: Springer-Verlag; 2003.)

measure calcaneal height in comparison with the contralateral heel, especially

after fracture or in cases of talar avascular necrosis or congenital abnormally.

Osteotomy rules
Bone deformity correction can be planned by drawing axis lines for each joint
segment and for each diaphysial segment. The intersection of each pair of axis
lines is called the CORA. In the frontal plane, one can use mechanical or anatomic axis lines for planning. In the sagittal plane, only anatomic axis lines are
used for planning [8]. The geometric result from osteotomy correction is directly
related to the CORA.

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Osteotomy rules are essential principles that must be understood before

surgical correction can begin [1]. Osteotomy rule 1 states that when the
osteotomy and the axis of correction of angulation (ACA) pass through a CORA,
the bone ends and axis lines will realign by angulation without translation. The
axes of the bone proximal and distal to the osteotomy will completely realign
when the magnitude of correction equals the magnitude of angulation (Fig. 16).
Osteotomy rule 2 states that when the ACA passes through the CORA but the
osteotomy is at a level different from that of the CORA, the axes of the bone will
realign with angulation and translation at the osteotomy site (Fig. 17). Osteotomy
rule 3 states that when the osteotomy and the ACA are at a level different from
that of the CORA, a translation deformity will result (Fig. 18).

Neutral
wedge

Closing
wedge

tBL

Opening
wedge

Fig. 16. Osteotomy rule 1: If the osteotomy and CORA are at the same location, no translation or
angulation occurs. An opening, neutral, or closing wedge osteotomy can be used. (From Paley D.
Principles of deformity correction. Berlin: Springer-Verlag; 2003.)

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319

tBL

Closing
wedge

Opening
wedge

Neutral
wedge

Fig. 17. Osteotomy rule 2: If the osteotomy is made away from the CORA, the segments must be
translated to align the proximal and distal axes. An opening, neutral, or closing wedge osteotomy
can be used. (From Paley D. Principles of deformity correction. Berlin: Springer-Verlag; 2003.)

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B.M. Lamm, D. Paley / Clin Podiatr Med Surg 21 (2004) 305326

Closing
wedge

tBL

Opening
wedge

Neutral
wedge

Fig. 18. Osteotomy rule 3: If the osteotomy is made away from the CORA, the segments will be
translated and not realigned. An opening, neutral, or closing wedge osteotomy can be used. (From
Paley D. Principles of deformity correction. Berlin: Springer-Verlag; 2003.)

The level of the CORA depends on the cause of the deformity. With congenital deformities of the distal tibia, the CORA usually is at the level of the
joint line, whereas in developmental deformities of the distal tibia, the CORA is
related to physis. Deformities occurring as a result of fracture can have a CORA
at any level, depending on the level of the fracture and associated translation

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321

deformity. If the plane of translation is the same as that of angulation, the CORA
will appear to be at the same level in all views. If the plane of translation is
different from the plane of angulation, the CORA will appear to be at different
levels in different views. Deformities with the CORA located in the diaphysis of a
long bone are more easily corrected by osteotomy performed at the level of the
CORA (osteotomy rule 1). Articulator deformities can be more difficult to correct
because the CORA is located at the joint line. Such deformities require translation
because the osteotomy must be made distant to the CORA (osteotomy rule 2). To
minimize loss of bone contact after an angulation-translation osteotomy, a
technique called focal dome osteotomy can be used. This is performed by
focusing the center of the circular bone cut at the CORA [1].

Frontal plane deformities

Compensatory joint motion must be assessed before realignment surgery is
performed. Frontal plane distal tibial varus/valgus deformities are normally
compensated for through the subtalar joint. The magnitude of the deformity
determines the amount of necessary subtalar joint compensation. The degree of
compensation that can be achieved depends on the amount of available subtalar
joint range of motion. The normal subtalar joint range of motion is 15 degrees of
eversion and 30 degrees of inversion. Thus, the largest amounts of distal tibial
deformity that can be compensated for are 30 degrees of valgus and 15 degrees of
varus when normal subtalar joint range of motion is present (Fig. 19).
When deformities are larger than the available subtalar joint motion, additional
compensation occurs through the forefoot by supination or pronation. For this

15
LDTA
= 105

LDTA
= 60

30

30
15

Fig. 19. Full compensation occurs at the subtalar joint for distal tibial valgus (30 degrees) and varus
(15 degrees) with a mobile subtalar joint. (From Paley D. Principles of deformity correction. Berlin:
Springer-Verlag; 2003.)

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reason, ankle varus and valgus are well tolerated if the subtalar joint and forefoot
are mobile. Deformities typically become symptomatic when the needed joint
motion exceeds the available joint motion. Varus of the distal tibia or tibial
plafond is typically tolerated less well than is valgus, because the available
subtalar joint compensation with eversion is less than with inversion.
Ankle varus deformities that exceed subtalar joint eversion motion lead to
compensatory forefoot pronation. The arch height increases as the first ray plantar
flexes to compensate for the excess varus, thereby decreasing the weight-bearing
surface of the foot. Ankle valgus deformities that exceed subtalar joint inversion
motion lead to compensatory forefoot supination. The arch height decreases as
the first ray dorsiflexes to compensate, thereby increasing the weight-bearing
surface of the foot.
In the normal foot, the GRV passes lateral to the midpoint of the ankle joint
because the anatomic axis of the calcaneus is lateral to that of the tibia. This
means that normally, a lateral moment arm acts on the tibiotalar joint, increasing
the load on the lateral side of the joint. This is resisted passively by a normal
length, normally located lateral malleolus and actively by the tibialis posterior
muscle. When the lateral malleolus is proximally or laterally migrated (e.g., after
an ankle fracture), the talus begins to shift laterally and develop lateral
degenerative changes. Similarly, when posterior tibial tendon dysfunction is
present, the valgus moment arm goes unchecked, leading to increased lateral joint
forces. These two examples serve as visible demonstrations of the effect of the
laterally located moment arm.
Varus deformities of the distal tibia or tibial plafond move the GRV medially
and are unlikely to lead to ankle degenerative joint changes. Furthermore, the
medial tilt of the ankle leads to weight bearing across the broad medial malleolar
cartilage, which is solidly fixed to the tibia with bone instead of fibrous tissue, as

Fig. 20. Varus of the distal tibia produces limited ankle joint arthritis. (From Paley D. Principles of
deformity correction. Berlin: Springer-Verlag; 2003.)

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323

Fig. 21. Valgus of the distal tibia produces early ankle joint arthritis and disruption of the ankle
mortise. (From Paley D. Principles of deformity correction. Berlin: Springer-Verlag; 2003.)

in the case of the lateral malleolus. Although varus deformities of the ankle do
not lead to ankle joint degeneration, they are more frequently symptomatic than
are valgus deformities because of the more limited compensatory subtalar motion
available (eversion). Degenerative changes and lateral impingement may develop
in the subtalar joint because of ankle varus deformities (Fig. 20).
Valgus ankle deformities increase the lateral moment arm and overload the
lateral side of the ankle joint despite being well compensated by the ample
subtalar inversion motion available. Consequently, the abnormal mechanics leads
to late degenerative changes. The tibialis posterior is unable to neutralize the
increased moment arm forces but increases the joint reactive forces in trying. The
lateral malleolus wears over time and can move away from the tibia because it is
fixed to it via soft tissues and not bone (Fig. 21).
Varus of the tibial plafond is diagnosed when the LDTA is greater than
92 degrees, as measured on an anteroposterior view radiograph. Valgus deformity of the tibial plafond is diagnosed when the LDTA is less than 86 degrees,
as measured on an anteroposterior view radiograph. The more proximal the deformity is from the ankle joint, the less effect it has on the joint orientation.

Sagittal plane deformities

Procurvatum and recurvatum deformities in the sagittal plane are compensated
through the ankle joint by dorsiflexion and plantar flexion, respectively. The
magnitude of the deformity determines the amount of necessary ankle joint
compensation. The degree of compensation that can be achieved depends on the
amount of available ankle joint range of motion. The normal ankle joint range of
motion is 20 degrees of dorsiflexion and 50 degrees of plantar flexion. Thus, the
largest amount of deformity that can be compensated for is 50 degrees of

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recurvatum and 20 degrees of procurvatum in a normal ankle joint. When

deformities are larger than the available ankle motion, some additional compensation occurs through the subtalar and midfoot joints. For these reasons, ankle
procurvatum and recurvatum are well-tolerated if the ankle, subtalar, and midfoot
joints are mobile.
Deformities typically become symptomatic when the needed joint motion
exceeds the available joint motion. Procurvatum of the distal tibia or tibial
plafond is typically less well tolerated than is recurvatum, because the available
ankle joint compensation in dorsiflexion is less than in plantar flexion. In
addition, anterior impingement of the neck of the talus on the anterior lip of
the distal tibia halt further compensation (Fig. 22). In the normal ankle, the GRV
passes anterior to the ankle joint, producing an anterior moment arm on the ankle
joint. This is resisted by the triceps surae muscle group. Distal tibial procurvatum
is diagnosed as an ADTA greater than 82 degrees, as measured on a mortise
lateral view radiograph. Procurvatum deformity of the distal tibia displaces the
foot posteriorly, decreasing the lever arm forces on the anterior ankle.
Distal tibial recurvatum is diagnosed when the ADTA is less than 78 degrees,
as measured on a mortise lateral view radiograph. Recurvatum of the distal tibia
tilts the cartilage anteriorly and typically presents late with pain. The delayed
onset of recurvatum symptoms occurs secondary to the large amount of available
compensatory plantar flexion. Recurvatum deformity uncovers the anterior talar
dome, thus decreasing the weight-bearing surface of the tibial plafond. Because
force is load per surface area, this greatly increases the force on the anterior ankle
joint, leading to late degenerative changes. As with valgus, recurvatum of the
distal tibia is well tolerated because of the large amount of available compensatory range of motion. As with valgus, recurvatum increases the lever arm forces
on the ankle and leads to late degenerative changes (Fig. 22). The worst de-

aADTA
= 60

aADTA
= 100

Recurvatum: shear

Procurvatum: impingement

Fig. 22. Recurvatum of the ankle (decreased ADTA) displaces the foot forward, uncovers the talus,
and increases shear forces on the ankle. Procurvatum (increased ADTA) of the ankle displaces the foot
posteriorly and can lead to anterior ankle impingement. (Reproduced with permission from SpringerVerlag [1]).

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325

formity for late degenerative changes, although well tolerated in the short term, is
valgus-recurvatum of the ankle. Recurvatum deformity displaces the ankle joint
center of rotation anteriorly, increasing the anterior lever arm. The only way to
reduce these lever arm forces is with the triceps surae muscles. When the foot is
plantigrade, the ankle is in equinus. This decreases the push off strength, and
therefore the compensatory ability of the triceps surae during gait, because the
gastrocnemius and soleus muscles are not at their optimal length:tension ratio.
Of all angular deformities of the distal tibia, recurvatum is the most likely to
produce arthritis.

Fixed compensatory motion

The compensatory positions of the ankle, subtalar, and midfoot joints may
become fixed if the osseous deformity remains for an extended period of time.
For example, chronic valgus deformity of the distal tibia compensated by subtalar
inversion may become fixed such that if the distal tibial deformity is corrected
with a supramalleolar osteotomy, the subtalar inversion contracture is uncovered
and the foot ends up in varus. Similarly, recurvatum deformity of the distal tibia
compensated by ankle plantar flexion ends up in equinus after osteotomy
correction if the ankle has lost dorsiflexion because of chronic plantar flexion
positioning. Therefore, it is essential to identify fixed compensatory motion before performing corrective osteotomy. Usually, this can be accomplished by
physical examination. If the foot can be placed in the maximum deformity
position, no fixed compensation (contracture) is present. If the foot cannot reach
the maximum deformity position, fixed compensatory contracture is present.
In the case of recurvatum osseous deformity with fixed compensatory equinus
contracture, the equinus needs to be corrected when the flexion supramalleolar
osteotomy is performed.
Supramalleolar osteotomies to correct distal tibial or ankle plafond deformities
stretch the posterior tibial nerve or cause osseous encroachment on the tarsal
tunnel. This stretch can cause an acute tarsal tunnel entrapment. Therefore, tarsal
tunnel decompressions are prophylactically performed for ankle deformity
correction from procurvatum to recurvatum, from varus to valgus, and from
internal to external rotation.

Summary
Clinical examination and radiographic reference lines comprise the foundation
for precise surgical planning. An understanding of radiographic angular relationships is critical for appropriate evaluation and identification of the level and
extent of deformity. Use of the aforementioned deformity principles for surgical
planning of osseous realignment and consideration of concomitant soft tissue
laxity/contracture and adjacent joint compensation are important for successful realignment.

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B.M. Lamm, D. Paley / Clin Podiatr Med Surg 21 (2004) 305326

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