Osteotomy: Indications, Types, Contraindications, Principles and Procedures

It is a surgery in which part of a bone is added or removed to change its length or alignment and improve a damaged joint.

The idea of ​​this operation is to change the damaged part of a joint to a healthy one.

Often, the osteotomy is performed in an attempt to correct an abnormality that has resulted from a trauma or illness.

This surgical intervention is commonly performed in people suffering from osteoarthritis.

Osteoarthritis damages the cartilage in a joint over time and an osteotomy can help people who have osteoarthritis in their hips or knees.

The osteotomy is able to correct the biomechanical alignment of the limb , increase the contact area or improve the congruence of the joint.

Indications for osteotomy

Growth discrepancy:

Growth disorders can be caused by trauma, disease or genetic predisposition, often due to premature closure in an injury.

This is especially a problem in the forearm and legs where two bones are present.

The unaffected bone continues to elongate, while the damaged bone lengthens at a slower pace, the normal bone will be forced to bend away from the shortened bone and will cause a deformity and altered orientation of the joint.

The osteotomy is necessary to straighten the deformity and return the limb to normal function and appearance.

Similarly, the trauma of the portion of a growth plate may result in selective slowing or cessation of growth on that side, while growth is normal on the unaffected side of the same bone.

For example, traumatism on the lateral side of the distal physis of the radius results in a wrist deformity.

The osteotomy is necessary to return the bone to the normal anatomical position.

Deformity after a malunion:

Diaphyseal and metaphyseal fractures may join in malposition and result in angular, rotational or shortened positions that require osteotomy.

Rotational deformities:

This can happen after a trauma or due to a deformation in the position of the baby in the uterus, known as tibial torsion.

Osteotomy may be necessary in severe cases that affect the function of the limb.

Discrepancy in length:

They are limb lengthening surgeries, using a device such as Ilizarov’s external tutor.

Correction of dysplasia:

This surgery is done to correct hip dysplasia.

It is usually done early before there are functional changes in the joints.

Contraindications

The osteotomy is contraindicated in cases of:

  • Neuropathic arthropathy.
  • Inflammatory arthropathy
  • Infections
  • Osteopenia severa.
  • Advanced arthritis

Principles of Osteotomy

To achieve the objectives that are posed with an osteotomy, the following principles must be met:

  • Accurate alignment and a narrowing of the gap must be achieved.
  • Rigid fixation must be provided, using internal or external fixation.
  • The soft tissues must be carefully protected.

Overview of the procedure

It is important to plan the procedure to minimize any possibility of error.

Pre-operative radiographs of the affected bone should be made as of the bones and the normal non-affected contralateral limb.

X-rays should include the entire joint above and below the deformed bone.

Rotational deformity can be missed on radiographs and should be measured clinically.

The correction must be planned at the site of greatest deformity.

The amount of bone resection, the angle of the osteotomy and the plane of the osteotomy should be planned well by preoperative schemes.

In the case of osteoarthritis in the knee, the surgeon will extract a piece of bone from the tibia.

If the damage to the knee joint is on the inside, this piece of bone will be taken from the outer side of the tibia.

This will tip the body weight towards the healthier section of the cartilage on the outside of the knee joint.

This ensures that the loads or weight are evenly distributed in the cartilage of the knee, which means that the deterioration of the cartilage ceases.

Once the surgeon has removed the piece of bone from the tibia, they will join the two parts of the bone and fix them.

If osteoarthritis is affecting the outside of the knee joint, the process is the same.

However, the bone piece will be removed from the inner side of the leg to shift the weight towards the inner side of the knee.

A hip osteotomy is the same type of operation, but the piece of bone that is removed is from the thigh bone.

The recovery of an osteotomy depends on the surgical techniques used.

However, you may be able to put all the weight on the joint after 10 to 12 weeks.

It could take up to a year to fully recover and adjust to the new leg position.

To help with a quick recovery, the patient will have to perform physical therapy to help with the realignment.

Types of osteotomies

Osteotomía transversal:

It is ideal for the correction of rotation only in the metaphyseal and diaphyseal region.

The osteotomy is performed in the area of ​​greater rotation cutting a transverse plane through the bone.

When the transverse osteotomy technique is used, the fixation is very stable.

Oblique osteotomy:

The oblique osteotomy allows two bones to separate or lengthen.

It can also be used to provide a rotational correction by placing the proximal obliquity in the medullary cavity of the distal fragment, thus providing a pivotal point for derotation and varus or valgus realignment.

Wedge osteotomy:

Also called cuneiform osteotomy, the wedge osteotomy is mainly used to correct the angular deformity, but it can be used for angular and rotation problems if both exist simultaneously.

Among the types of wedge osteotomy can be mentioned:

Open wedge osteotomy:

The cut is made at the desired site and a wedge of bone is inserted into the concave surface. Produces bone lengthening.

Closed wedge osteotomy:

A predetermined bone size is removed from the point of maximum deformity with the base of the wedge on the convex surface of the deformity.

The space closes, correcting the angle and fixed.

The closed wedge produces a slight shortening of the bones.

Osteotomies can be stabilized using fixation elements that are made of biodegradable materials, stainless steel and titanium.

The conventional forms of internal or external fixation use elements such as:

  • Internal fixation: poles and staples, spines and needles, wires, screws, plates and intramedullary nails.
  • External fixation: Uniplanar standard, Ilizarov annular fixator, hybrid fixators (two uniplanar or one uniplanar and one annular fixator).