12/21/2025
Two examples of what “seem to be” straightforward ankles with some important considerations during workup and intraoperative decision making.
Case 1-Prior nonoperative mid shaft tib/fib with subsequent TKA. Bowing of the tibia should not be ignored if considering a PSI approach. If the alignment is based off of the distal tibia, a re**us stemmed implant appearing congruous within the medullary canal of the tibia can result in malalignment with the mechanical axis of the tibia (MAT).
The tibial stem in this example is parallel to the MAT, although appears to be headed slightly lateral toward tibial cortex. Proximal tib/fib radiographs are imperative intraoperatively.
Case 2- Valgus ankle performed in a single stage without deltoid ligamentous augmentation. Long leg alignment views were taken preoperatively and this was performed in a single stage given the deformity at the hindfoot was equivalent to that of the ankle per our algorithm.
The deformity is reduced to neutral and a wire is placed to hold the ankle at a neutral position. This is fashioned anteriorly to avoid convergence during entry of the peck drill.
Some considerations-Soft tissue tension is truly gauged intraoperatively and standard instrumentation can allow for varying degrees of bone resection (ie. Resecting more bone for a “tight” ankle and less for a “loose” ankle”). We prefer standard instrumentation for these reasons.
Key takeaway-never ignore proximal chain kinetics.
