Supramalleolar Osteotomy for Varus Ankle Osteoarthritis: A Contemporary Narrative Review

Background and Objectives: Varus ankle osteoarthritis (OA) is most commonly post-traumatic and is characterized by asymmetric degeneration and medial overload of the tibiotalar joint. Supramalleolar osteotomy (SMOT) is a joint-preserving procedure that aims to restore mechanical alignment, redistribute joint contact forces, and delay, or potentially avoid, total ankle replacement (TAR) or ankle arthrodesis (AA). However, the optimal choice of technique and amount of correction remain debated, particularly in complex multiplanar deformities. Materials and Methods: This narrative review summarizes current evidence on SMOT for varus ankle OA. Relevant clinical, radiographic, biomechanical, imaging, and surgical studies were selected and synthesized narratively, with particular emphasis on deformity classification, location of the center of rotation of angulation (CORA), joint congruency, surgical technique, clinical outcomes, complications, and treatment planning. Results: SMOT provides reliable pain relief and functional improvement in patients with Takakura–Tanaka stage 2–3A ankle OA, with reported mid-term survival rates of 88–93%. The choice of technique should be guided by the location of the deformity, the degree of talar tilt, and overall limb alignment. In selected cases, a concomitant fibular osteotomy improves talar reduction and medial unloading. Three-dimensional planning and patient-specific instrumentation may improve the accuracy of correction. Conclusions: SMOT is an effective joint-preserving treatment for varus ankle OA, provided that the deformity is accurately analyzed and patients are carefully selected. This review proposes a simplified, stepwise treatment algorithm, supported by illustrations, to help surgeons select the most appropriate osteotomy technique according to the deformity pattern.