Osteotomy

Incision or transection of bone.
Uses:-
to correct deformity.
to change shape of bone.
to redirect load trajectories in a limb so as to influence joint function.

1. Rabins kumar sah third year resident orthopaedics nmcth , birgunj OSTEOTOMY

2. Definition: Incision or transection of bone. Uses:- to correct deformity. to change shape of bone. to redirect load trajectories in a limb so as to influence joint function.

3. Preoperative planning is essential: After internal fixation is in place and skin closed, adjustments are very difficult to make, especially after closing wedge osteotomies . Rotational malalignment is assessed clinically, but if precise measurements are desired CT scans are useful . how changes in angulation and rotation will affect overall length of extremity.

4. RULES FOR OSTEOTOMY Intersection of anatomical axes is referred to as a centre of rotation of angulation (CORA) . it can also be determined by noting intersection of mechanical axes of the segments proximal and distal to deformity.

5. I mportant of CORA 1. It indicates where an axis of rotation, named angulation correction axis or ACA (Paley, 2002), should be placed about which two intersecting axes of the CORA can be brought in line and hence deformity corrected.

6. This axis of rotation, which enables appropriate realignment of intersecting axes, should be positioned on either side of CORA but along a line termed ‘ the bisector’. Bisector :- line that bisects angle described by deformity .

7. Effect of placing axis of rotation on convex side of deformity is to envisage an opening wedge correction, and conversely if it is placed on the concave side – a closing wedge correction. Moving the rotation axis further along bisector increases or decreases the size of opening, i.e. achieves simultaneous lengthening or shortening with angular correction .

8. If rotation axis is not placed on bisector, a translation deformity will ensue despite satisfactory correction of angulation . 2. Presence of translation as well as angulation as components of deformity and can also indicate presence of multi-apical deformities.

9. (a) When the CORA is identified and is found to lie within the boundaries of bone involved as well as coinciding in level with apex of deformity, this indicates only an angular component to deformity. Rotation axis to correct deformity can be sited on bisector and osteotomy performed at same level – this is equivalent to classic correction through opening or closing wedge methods .

10. (b) When CORA lies within boundaries of bone involved but is at a different level to that of apex of deformity, it indicates presence of translation and angulation within deformity . Rotation axis to enable correction should be maintained on bisector of CORA but osteotomy can be sited at either of two levels (coincident with apex of deformity or at CORA):

11. b(1) when positioned on former, correction of both translation and angulation is simultaneously accomplished at site of original deformity. b(2) when sited on latter, a new deformity is created which correctly ‘balances’ the malalignment produced from original site.

12. (c) When the CORA lies outside boundaries of involved bone, a multi-apical deformity is likely to be present (and the deformity more akin to a curve). deformity would need to be resolved through multiple osteotomies .

13. These features of the CORA are, in essence, the rules of osteotomy as described by Paley (2002). “It explains why it is permissible to perform osteotomies away from apex of the deformity as long as correction is achieved through a rotation axis placed on CORA or on its bisector.”

14. Types of osteotomies : A: Opening wedge. B: Closing wedge. C: Displacement. D: Stepcut . E: Crescentic (dome). F: Transverse derotation . G: Oblique (single plane).

15. TRANSVERSE OSTEOTOMY Ideal for correcting rotation alone. Diaphysis or metaphysis plane of cut is transverse to long axis of bone to avoid frontal or sagittal deformity. Simple to perform but it is relatively unstable and is not ideally suited for interfragmentary compression. Resists axial load but weak to torsion or bending loads. Angular corrections difficult to control .

16. CLOSING WEDGE OSTEOTOMY Removing predetermined sized wedge of bone from maximal deformity. base of wedge is at covex surface of deformity. After removing wedge gap is closed and internal fixation done. commonly used high tibial osteotomy performed to treat unicompartmental arthritis of the knee. advantages :-are simplicity, stability, and rapidity of healing. Disadvantages:- are that it can affect soft-tissue balance if close to joints, and it will result in some shortening.

17. OPENING WEDGE OSTEOTOMY :- Single transverse cut was used and wedge is opened on concave surface with bone graft. Base of wedge is on concave surface and apex on convex surface. Advantage - some gain in length. Disadvantages :- filled by a bone graft, which slows healing, nonunions can occur, and the intercalary bone graft used must remodel before full weight bearing can begin.

18. OBLIQUE (SINGLE-PLANE) OSTEOTOMY It can correct all deformities with a single cut. broader surface area for healing. Compression at site. Can lengthen. No graft . Creates some rotation. useful in the metaphyseal region.

19. CRESCENTIC (DOME) OSTEOTOMY Used in metaphyseal or epiphyseal cancellous bone, where irregular nature of bone and cut provide good inherent stability, and broad surface area and cancellous bone lead to rapid healing . Dome shaped – one side shallow and another side deep cut was done done and deformity was corrected . Bone saving procedure. It is ideal for correcting deformity near joints that are in a single plane, preferably the frontal plane.

20. DISPLACEMENT OSTEOTOMY Described by wagner is useful to address a major juxtaarticular deformity . Transverse metaphyseal osteotomy in which periarticular fragment is rotated, impacting one corner of the metaphysis into medullary canal of other fragment. This transforms bending loads into compressive loads while preserving length and improving joint alignment.

21. STEPCUT OSTEOTOMY:- In rare cases, such as one-stage diaphyseal lengthening. Rotational and angular corrections are limited .

22. COMPLICATIONS OF OSTEOTOMY AND DEFORMITY CORRECTION:- General : thrombo - embolism and infections. Undercorrection and overcorrection. Nerve tension: acute long-bone corrections > 20 degrees should be avoided and if there is a known risk of nerve injury it should be limited to 10 degrees. example is peroneal nerve palsy

23. Compartment syndrome: Osteotomy of the tibia or forearm bones. Non-union: may occur if fixation is inadequate or if soft tissues are damaged by excessive stripping during surgical exposure.

24. D eformities around the Elbow joint Cubitus Varus . Cubitus Valgus . Malunion of radial head #. Malunion of radial neck #. Malunion of olecranon of ulna #. Proximal radio- ulnar synostosis . Malunited Monteggia fracture .

25. Osteotomies around elbow joint :-

26. Cubitus Varus

27. Deviation of forearm inward with respect to arm at elbow . Lateral angulation of elbow in full extension.

28. Crude approx.Change of 5 degree in Baumann’s angle will produce 2 degree varus deformity. General rule 1cm osteotomy will correct 10 degree of deformity.

29. Prerequisites: One year following fracture Patient demand.

30. AVAILABLE OSTEOTOMIES: Three basic types: Medial opening wedge osteotomy with bone graft Oblique osteotomy with derotation , and Lateral closing wedge osteotomy .

31. LATERAL CLOSING WEDGE OSTEOTOMY

32. A/C to Voss et al:- Approach - lateral incision. Closing wedge osteotomy laterally, leaving medial cortex intact . Medial cortex was weaken using drill holes and a rongeur . Applying forceful valgus stress to complete osteotomy with forearm in pronation and elbow flexed .

33. AFTER TREATMENT: wires removed 6 to 8 weeks after surgery then range-of-motion.

34. Medial Approach: Medial incision. Protecting ulnar nerve . Bipolar diathermy was used to prevent neural damage from leakage of diathermy current. Distal humeral metaphysis was exposed through posteromedial intramuscular plane.

35. laterally based closing wedge osteotomy with power saw parallel to guidewires . osteotome used to complete wedge excision at far cortex. internal rotation of distal fragment corrected in all cases with severe deformity. Distal fragment translated medially to reduce lateral condylar prominence. two crossed K- wires percutaneously inserted for fixation.

36. AFTER TREATMENT : Immobilized in a long-arm cast for 3 to 4 weeks. Kirschner wires are removed. Protected elbow mobilization is initiated.

37. French: Posterior longitudinal incision.  Triceps muscle and aponeurosis was splitted , detaching lateral half of triceps from its insertion, and reflecting it proximally. Posterior surface ,lateral border of humerus and ulnar nerve exposed. Distal screw in anterior part of distal fragment and proximal screw in posterior part of proximal fragment was inserted.

38. Motor saw was used to excise wedge of bone leave periosteum intact medially to act as a hinge. Deformity was corrected by rotating distal fragment externally until distal screw is directly distal to proximal screw. Maintain this position by tightening wire loop around heads of two screws. This procedure minimized danger of damaging physis .

39. French, Modified by Bellemore et al. Posterolateral incision. Triceps was splitted , detaching it from its insertion, and reflect it proximally. Lifting middle two thirds of the muscle from humerus subperiosteally . Protecting the neurovascular bundle.

40. Laterally wedging done, ending just short of the medial cortex. Proximal and distal screw placed in lateral cortex at an angle approximating that of the wedge to be resected . Wedge was resected with an oscillating saw, leaving its apex intact at medial cortex.

41. Elbow was extended and closing wedge by fracturing medial cortex, leaving cortex and periostum intact as hinge. Forearm placed in supination , and carrying angle evaluated.. If necessary rotational deformity corrected by offsetting distal screw. Distal fragment derotated , rotational deformity corrected, and align it with superior screw. Tighten the wires around the screw heads.

42. AFTER TREATMENT elbow is flexed 90 degrees with forearm in neutral rotation in a posterior plastic splint for 3 weeks. then ROM

43. Oblique Osteotomy with Derotation ( Amspacher and Messenbaugh ) Posterior longitudinal incision Tongue of triceps fascia was made and triceps muscle divided in line with its fibers . Subperiosteal exposure of supracondylar part of humerus , protecting radial and ulnar nerves in the periphery of wound.

44. Oscillating saw used to make oblique osteotomy about 3.8 cm proximal to the distal end of humerus , directing it from posteriorly above to anteriorly below. Complete it anteriorly with an osteotome . Tilting and rotating of distal fragment until the internal rotation and cubitus varus corrected. Fragments was fixed with screw inserted across middle of osteotomy .

45. AFTER TREATMENT Arm is immobilized in a long-arm splint or cast until union is solid at 4 to 6 weeks.

46. Step-Cut Osteotomy ( DeRosa and Graziano ) Posterior approach. Reflect triceps tendon, protecting the ulnar and radial nerves. Lateral closing wedge osteotomy in metaphyseal region superior to olecranon fossa . Placing apex of template (angle to be corrected) medially with the superior margin perpendicular to the humeral shaft.

47. Inferior margin joined to superior margin to outline osteotomy . Osteotomy wedge removed, leaving a lateral spike of bone on distal fragment. Some trimming of lateral part of proximal fragment may be necessary for close approximation of osteotomy .

48. AFTER TREATMENT Cast is removed at 4 weeks and active range-of-motion . Posterior shell is used for protection between exercise periods until union is obtained.

49. Uchida et al. Three-dimensional osteotomy . Medial and posterior tilt and rotation of distal fragment corrected . After osteotomy , distal fragment is compacted with proximal fragment by adding external rotation using wedge of humeral cortex. Bone graft is added if necessary.

50. Cubitus Valgus

51. Cubitus valgus seems to occur, not from premature closure of the capitellar physis , but from nonunion with proximal migration of the lateral condyle (Fig. 33-61). This occurs most often after displaced fractures.