Osteotomy

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Osteotomy
ICD-9-CM 77.3
MeSH D010027

An osteotomy is a surgical operation whereby a bone is cut to shorten or lengthen it or to change its alignment. It is sometimes performed to correct a hallux valgus, or to straighten a bone that has healed crookedly following a fracture. It is also used to correct a coxa vara, genu valgum, and genu varum. The operation is done under a general anaesthetic. [1]

Contents

Osteotomy is one method to relieve pain of arthritis, especially of the hip and knee. It is being replaced by joint replacement in the older patient. [2]

Due to the serious nature of this procedure, recovery may be extensive. Careful consultation with a physician is important in order to ensure proper planning during a recovery phase. Tools exist to assist recovering patients who may have non–weight bearing requirements and include bedpans, dressing sticks, long-handled shoe-horns, grabbers/reachers and specialized walkers and wheelchairs.

Osteotomies of the hip

X-ray of Femoral Osteotomy hardware to correct femoral rotation caused by hip dysplasia. X-ray of the right hip in female patient in early thirties. FO after.jpg
X-ray of Femoral Osteotomy hardware to correct femoral rotation caused by hip dysplasia. X-ray of the right hip in female patient in early thirties.

Two main types of osteotomies are used in the correction of hip dysplasias and deformities to improve alignment/interaction of acetabulum – (socket) – and femoral head (femur head) – (ball), innominate osteotomies and femoral osteotomies. The bones are cut, reshaped or partially removed to realign the load-bearing surfaces of the joint. [3]

a. X-ray of a hip after capsulorrhaphy and Dega surgery.
b. Same hip after addition of Chiari medial displacementosteotomy. X-ray of the hip after (a) open reduction, capsulorrhaphy and Dega and (b) Chiari surgery.jpg
a. X-ray of a hip after capsulorrhaphy and Dega surgery.
b. Same hip after addition of Chiari medial displacementosteotomy.

Adjustments are made to part of the hip-bone. Many operating methods and variations have been developed. They are defined by the type of cut and adjustment made. Some acetabular procedures are named after the surgeons who first described them as Salter (R. Salter), Dega (W. Dega), Sutherland (D.H. Sutherland), Chiari (K. Chiari): other names one may encounter are Ludlov, P. Pemberton, and James B. Steele. Some are named after the shape of cut (e.g. Chevron, Wedge) or the way the bones are aligned (Dial=old style rotary dial phone).

A femoral derotation osteotomy can be performed to correct version abnormalities such as excessive anteversion or retroversion of the hip joint. Excessive anteversion of the femur results in anterior instability of the hip joint while excessive retroversion results in femoroacetabular hip impingement. [5]

A subtrochanteric blade plate or an intramedullary rod can be used to stabilize the osteotomy site in a femoral derotation osteotomy until compete bone healing is achieved; an approach employing an intramedullary rod is much less invasive than one using a subtrochanteric blade plate.[ citation needed ]}

Femoral osteotomies, as the name indicates, involves adjustments made to the femur head and/or the femur. [6]

Osteotomy of the knee

Valgus osteotomy. The black line is the mechanical axis. Osteotomy tibia en.svg
Valgus osteotomy. The black line is the mechanical axis.

Knee osteotomy is commonly used to realign arthritic damage on one side of the knee. The goal is to shift the patient's body weight off the damaged area to the other side of the knee, where the cartilage is still healthy. Surgeons remove a wedge of the tibia from underneath the healthy side of the knee, which allows the tibia and femur to bend away from the damaged cartilage. [7]

A model for this is the hinges on a door. When the door is shut, the hinges are flush against the wall. As the door swings open, one side of the door remains pressed against the wall as space opens up on the other side. Removing just a small wedge of bone can "swing" the knee open, pressing the healthy tissue together as space opens up between the femur and tibia on the damaged side so that the arthritic surfaces do not rub against each other.[ citation needed ]

Osteotomy is also used as an alternative treatment to total knee replacement in younger and active patients. Because prosthetic knees may wear out over time, an osteotomy procedure can enable younger, active osteoarthritis patients to continue using the healthy portion of their knee. The procedure can delay the need for a total knee replacement for up to ten years. [8]

Surgery

The location of the removed wedge of bone depends on where osteoarthritis has damaged the knee cartilage. The most common type of osteotomy performed on arthritic knees is a high tibial osteotomy, which addresses cartilage damage on the inside (medial) portion of the knee. The procedure usually takes 60 to 90 minutes to perform. [9]

During a high tibial osteotomy, surgeons remove a wedge of bone from the outside of the knee, which causes the leg to bend slightly inward. This resembles the realigning of a bowlegged knee to a knock-kneed position. The patient's weight is transferred to the outside (lateral) portion of the knee, where the cartilage is still healthy. [10]

After regional or general anesthesia is administered, the surgical team sterilizes the leg with antibacterial solution. Surgeons map out the exact size of the bone wedge they will remove, using an X-ray, CT scan, or 3D computer modeling. A four- to five-inch incision is made down the front and outside of the knee, starting below the kneecap and extending below the top of the shinbone.Guide wires are drilled into the top of the shinbone (tibia plateau) from the outside (lateral side) of the knee. The wires usually outline a triangle form in the shinbone.[ citation needed ]

A standard oscillating saw is run along the guide wires, removing most of the bone wedge from underneath the outside of the knee, below the healthy cartilage. The cartilage surface on the top of the outside (lateral side) of the shinbone is left intact. The top of the shinbone is then lowered on the outside and attached with surgical staples or screws, depending on the size of the wedge that was removed. The layers of tissue in the knee are stitched together, usually with absorbable sutures.

Rehabilitation and prevention

A fall or torque to the leg during the first two months after surgery may jeopardize healing. Patients must exercise extreme caution during all activities, including walking, until healing is complete.[ citation needed ]

After rehabilitation, preventing osteoarthritis involves slowing the progression and spread of the disease. Maintaining aerobic cardiovascular fitness has been an effective method for preventing the progression of osteoarthritis. Light, daily exercise is much better for an arthritic knee than occasional, heavy exercise. [11]

It is especially important to avoid any serious knee injuries, such as torn ligaments or fractured bones, because arthritis can complicate knee injury treatment. High-impact or repetitive stress sports, like football and distance running, should be avoided.

Because osteoarthritis has multiple causes and may be related to genetic factors, no universal prevention tactic exists.

General recommendations include:

Osteotomy of the jaw

This is performed to realign the mandible (lower jaw) or maxilla (upper jaw) with the rest of the skull and/or teeth. This is usually performed to correct skeletal malocclusions, that is discrepancies in tooth position that cannot be corrected by simple orthodontic movement, and realignment of the temporomandibular joints, or to correct facial deformities such as mandibular retrognathia. [12] There is little scarring, and all of the surgery takes places inside of the mouth. Orthodontic braces may have to be worn pre- and post- operation to realign the teeth to match the newly realigned jaw.

Osteotomy of the chin

Chin osteotomy is most often done to correct a vertically short chin. As opposed to putting an implant on top of the chin bone to bring it forward, an alternative approach is to cut the chin bone itself and bring it forward or other directions as well. It can also be used to lengthen the chin (which is more difficult with an implant) or to shorten or narrow a chin. (which is impossible with an implant). [13]

Chin osteotomies (cutting the bone and moving it) are done through an incision inside the mouth. It is technically more difficult than an implant and has more swelling and recovery than a simple chin implant. Also, there is usually temporary loss of feeling of the lip and chin after that takes several weeks to months for full return of sensation.[ citation needed ]

Veterinary osteotomy procedures

In veterinary medicine, osteotomies are frequently performed to address rupture of the canine cranial cruciate ligament, which is analogous to the anterior cruciate ligament. The tibial plateau leveling osteotomy and tibial tuberosity advancement are two of the most common osteotomy procedures performed in the United States. Recovery is often 6–8 weeks and the osteotomy can be filled with autologous bone grafts, scaffolds (hydroxyapatite, TR Matrix, etc.) or ceramics. [14]

See also

Related Research Articles

<span class="mw-page-title-main">Knee</span> Leg joint in primates

In humans and other primates, the knee joins the thigh with the leg and consists of two joints: one between the femur and tibia, and one between the femur and patella. It is the largest joint in the human body. The knee is a modified hinge joint, which permits flexion and extension as well as slight internal and external rotation. The knee is vulnerable to injury and to the development of osteoarthritis.

<span class="mw-page-title-main">Hip dysplasia (canine)</span> Joint abnormality in dogs

In dogs, hip dysplasia is an abnormal formation of the hip socket that, in its more severe form, can eventually cause lameness and arthritis of the joints. It is a genetic (polygenic) trait that is affected by environmental factors. It is common in many dog breeds, particularly the larger breeds, and is the most common single cause of arthritis of the hips.

<span class="mw-page-title-main">Orthopedic surgery</span> Branch of surgery concerned with the musculoskeletal and bones system

Orthopedic surgery or orthopedics is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal trauma, spine diseases, sports injuries, degenerative diseases, infections, tumors, and congenital disorders.

<span class="mw-page-title-main">Coxa vara</span> Deformity of the hip

Coxa vara is a deformity of the hip, whereby the angle between the head and the shaft of the femur is reduced to less than 120 degrees. This results in the leg being shortened and the development of a limp. It may be congenital and is commonly caused by injury, such as a fracture. It can also occur when the bone tissue in the neck of the femur is softer than normal, causing it to bend under the weight of the body. This may either be congenital or the result of a bone disorder. The most common cause of coxa vara is either congenital or developmental. Other common causes include metabolic bone diseases, post-Perthes deformity, osteomyelitis, and post traumatic. Shepherd's Crook deformity is a severe form of coxa vara where the proximal femur is severely deformed with a reduction in the neck shaft angle beyond 90 degrees. It is most commonly a sequela of osteogenesis imperfecta, Paget's disease, osteomyelitis, tumour and tumour-like conditions.

<span class="mw-page-title-main">Genu valgum</span> Medical condition known as knock-knee

Genu valgum, commonly called "knock-knee", is a condition in which the knees angle in and touch each other when the legs are straightened. Individuals with severe valgus deformities are typically unable to touch their feet together while simultaneously straightening the legs. The term originates from the Latin genu, 'knee', and valgus which means "bent outwards", but is also used to describe the distal portion of the knee joint which bends outwards and thus the proximal portion seems to be bent inwards.

<span class="mw-page-title-main">Genu varum</span> Varus deformity marked by (outward) bowing at the knee

Genu varum is a varus deformity marked by (outward) bowing at the knee, which means that the lower leg is angled inward (medially) in relation to the thigh's axis, giving the limb overall the appearance of an archer's bow. Usually medial angulation of both lower limb bones is involved.

<span class="mw-page-title-main">Valgus deformity</span> Deformity in which the bone near a joint is angled outward

A valgus deformity is a condition in which the bone segment distal to a joint is angled outward, that is, angled laterally, away from the body's midline. The opposite deformation, where the twist or angulation is directed medially, toward the center of the body, is called varus. Common causes of valgus knee in adults include arthritis of the knee and traumatic injuries.

<span class="mw-page-title-main">Hip replacement</span> Surgery replacing hip joint with prosthetic implant

Hip replacement is a surgical procedure in which the hip joint is replaced by a prosthetic implant, that is, a hip prosthesis. Hip replacement surgery can be performed as a total replacement or a hemi/semi(half) replacement. Such joint replacement orthopaedic surgery is generally conducted to relieve arthritis pain or in some hip fractures. A total hip replacement consists of replacing both the acetabulum and the femoral head while hemiarthroplasty generally only replaces the femoral head. Hip replacement is one of the most common orthopaedic operations, though patient satisfaction varies widely. Approximately 58% of total hip replacements are estimated to last 25 years. The average cost of a total hip replacement in 2012 was $40,364 in the United States, and about $7,700 to $12,000 in most European countries.

Arthroplasty is an orthopedic surgical procedure where the articular surface of a musculoskeletal joint is replaced, remodeled, or realigned by osteotomy or some other procedure. It is an elective procedure that is done to relieve pain and restore function to the joint after damage by arthritis or some other type of trauma.

<span class="mw-page-title-main">Knee replacement</span> Surgical procedure

Knee replacement, also known as knee arthroplasty, is a surgical procedure to replace the weight-bearing surfaces of the knee joint to relieve pain and disability, most commonly offered when joint pain is not diminished by conservative sources. It may also be performed for other knee diseases, such as rheumatoid arthritis. In patients with severe deformity from advanced rheumatoid arthritis, trauma, or long-standing osteoarthritis, the surgery may be more complicated and carry higher risk. Osteoporosis does not typically cause knee pain, deformity, or inflammation, and is not a reason to perform knee replacement.

<span class="mw-page-title-main">Joint replacement</span> Orthopedic surgery to replace a joint

Joint replacement is a procedure of orthopedic surgery known also as arthroplasty, in which an arthritic or dysfunctional joint surface is replaced with an orthopedic prosthesis. Joint replacement is considered as a treatment when severe joint pain or dysfunction is not alleviated by less-invasive therapies. Joint replacement surgery is often indicated from various joint diseases, including osteoarthritis and rheumatoid arthritis.

A meniscus transplant or meniscal transplant is a transplant of the meniscus of the knee, which separates the thigh bone (femur) from the lower leg bone (tibia). The worn or damaged meniscus is removed and is replaced with a new one from a donor. The meniscus to be transplanted is taken from a cadaver, and, as such, is known as an allograft. Meniscal transplantation is technically difficult, as it must be sized accurately for each person, positioned properly and secured to the tibial plateau. As of 2012, only a few surgeons have significant volume of experience in meniscus transplantation worldwide.

<span class="mw-page-title-main">Hip dysplasia</span> Joint abnormality

Hip dysplasia is an abnormality of the hip joint where the socket portion does not fully cover the ball portion, resulting in an increased risk for joint dislocation. Hip dysplasia may occur at birth or develop in early life. Regardless, it does not typically produce symptoms in babies less than a year old. Occasionally one leg may be shorter than the other. The left hip is more often affected than the right. Complications without treatment can include arthritis, limping, and low back pain. Females are affected more often than males. Risk factors for hip dysplasia include female sex, family history, certain swaddling practices, and breech presentation whether an infant is delivered vaginally or by cesarean section. If one identical twin is affected, there is a 40% risk the other will also be affected. Screening all babies for the condition by physical examination is recommended. Ultrasonography may also be useful.

Articular cartilage repair treatment involves the repair of the surface of the articular joint's hyaline cartilage. Over the last few decades, surgeons and researchers have made progress in elaborating surgical cartilage repair interventions. Though these solutions do not perfectly restore the articular cartilage, some of the latest technologies have started to bring very promising results in repairing cartilages from traumatic injuries or chondropathies. These treatments have been shown to be especially beneficial for patients who have articular cartilage damage. They can provide some measure of pain relief, while at the same time slowing down the accumulation of damage, or considerably delaying the need for joint replacement surgery.

<span class="mw-page-title-main">Pigeon toe</span> Medical condition affecting the feet

Pigeon toe, also known as in-toeing, is a condition which causes the toes to point inward when walking. It is most common in infants and children under two years of age and, when not the result of simple muscle weakness, normally arises from underlying conditions, such as a twisted shin bone or an excessive anteversion resulting in the twisting of the thigh bone when the front part of a person's foot is turned in.

<span class="mw-page-title-main">Hip arthroscopy</span>

Hip arthroscopy refers to the viewing of the interior of the acetabulofemoral (hip) joint through an arthroscope and the treatment of hip pathology through a minimally invasive approach. This technique is sometimes used to help in the treatment of various joint disorders and has gained popularity because of the small incisions used and shorter recovery times when compared with conventional surgical techniques. Hip arthroscopy was not feasible until recently, new technology in both the tools used and the ability to distract the hip joint has led to a recent surge in the ability to do hip arthroscopy and the popularity of it.

High tibial osteotomy is an orthopaedic surgical procedure which aims to correct a varus deformation with compartmental osteoarthritis. Since the inception of the procedure, advancements to technique, fixation devices, and a better understanding of patient selection has allowed HTO to become more popular in younger, more active patients hoping to combat arthritis. The idea behind the procedure is to realign the weight-bearing line of the knee. By realigning the knee, the force produced from weight-bearing is shifted from the arthritic, medial compartment to the healthy, lateral compartment. This decrease in force or load in the diseased part of the knee joint decreases knee pain and can delay the development or progression of osteoarthritis in the medial compartment.

<span class="mw-page-title-main">Index of trauma and orthopaedics articles</span>

Orthopedic surgery is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal injuries, sports injuries, degenerative diseases, infections, bone tumours, and congenital limb deformities. Trauma surgery and traumatology is a sub-specialty dealing with the operative management of fractures, major trauma and the multiply-injured patient.

<span class="mw-page-title-main">Raju Vaishya</span> Indian researcher

Raju Vaishya is an Indian researcher with contributions in the field of orthopaedics. He is former President and founder member of Indian Cartilage Society (2018–19) and Founder President of Arthritis Care Foundation. He has established a center for Autologous Chondrocyte Implantation (ACI) at Indraprastha Apollo Hospitals, New Delhi, India. Instrumental (PSI) in starting the first cartilage club in Delhi, to enhance the awareness about the cartilage science and regenerative treatments used in Orthopaedics. He has the credit of doing the first preplan patient specific instruments (PSI) total knee arthroplasty, in Northern India in May 2013.

Bone malrotation refers to the situation that results when a bone heals out of rotational alignment from another bone, or part of bone. It often occurs as the result of a surgical complication after a fracture where intramedullary nailing (IMN) occurs, especially in the femur and tibial bones, but can also occur genetically at birth. The severity of this complication is often neglected due to its complexity to detect and treat, yet if left untreated, bone malrotation can significantly impact regular bodily functioning, and even lead to severe arthritis. Detection throughout history has become more advanced and accurate, ranging from clinical assessment to ultrasounds to CT scans. Treatment can include an osteotomy, a major surgical procedure where bones are cut and realigned correctly, or compensatory methods, where individuals learn to externally or internally rotate their limb to compensate for the rotation. Further research is currently being examined in this area to reduce occurrences of malrotation, including detailed computer navigation to improve visual accuracy during surgery.

References

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Further reading