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.

6. Important 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.

7.  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 .

8.  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 .

10.  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.

11.  (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 .

12.  (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):

14.  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.

15.  (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.

16.  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.”

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

18. 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 .

19. 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.

20. 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.

21. 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.

23. 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.

25. 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.

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

27. COMPLICATIONS OF OSTEOTOMYAND
DEFORMITYCORRECTION:-
 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

28.  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.

29. Deformities 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 .

30. Osteotomies around elbow joint :-

31. Cubitus Varus

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

35.  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.

36. Prerequisites:
 One year following fracture
 Patient demand.

37. AVAILABLE OSTEOTOMIES:
 Three basic types:
1) Medial opening wedge osteotomy with bone
graft
2) Oblique osteotomy with derotation, and
3) Lateral closing wedge osteotomy.

38. LATERAL CLOSING WEDGE OSTEOTOMY

39. 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 .

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

42. MedialApproach:
 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.

43.  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.

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

46. 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.

48.  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 .

50. 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.

51.  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.

52.  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.

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

54. 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.

55.  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.

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

57. 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.

58.  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.

62. 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.

63. 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.

68. Cubitus Valgus

69.  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.