Procedures

Laminectomy is a surgical procedure for decompressing the cord or nerve roots by removal of lamina part of the vertebra which forms the vertebral or neural arch.

The vertebral arch is the ring of bone that joins the vertebral body to surround the spinal cord. [see anatomy]

Each vertebra contains two laminae and the procedure may remove one or both laminae. Removal of the single lamina is called hemilaminectomy.

Although the literal meaning of laminectomy is ‘excision of the lamina’, a conventional laminectomy involves excision of the posterior spinal ligament and some or all of the spinous process

The main aim of the laminectomy is to relieve the pressure on the nerve tissues.

It can be done as the stand-alone procedure or may be done as part of some other procedure. For example, laminectomy may be done to access the disc better for its removal.

Laminectomy is most commonly done in the lumbar spine. It is done less often in the cervical spine and even more rarely in thoracic.

Spinal stenosis is the most common indication of laminectomy. Discectomy also involves cutting of lamina but most of the surgeries now preserve lamina or do partial laminectomy only.

Depending on the disease levels, the laminectomy may be done for a single vertebra or multiple levels.

In some cases, spinal fixation and fusion may be done. Fusion aims at prevention of the recurrence.

Laminectomy versus Laminotomy

Laminectomy and laminotomy, both are procedures for decompression of the cord or roots

Laminectomy is the removal of the entire bony lamina, a portion of the enlarged facet joints, and the thickened ligaments overlying the spinal cord and nerves.

Laminotomy is the removal of a small portion of the lamina and ligaments. It is usually done on one side., usually on one side. This procedure is often done for accessing the disc. It has the advantage of leaving the lamina in place, decreasing the chance of postoperative spinal instability.

Relevant Anatomy

Each vertebra consists of an anterior body which is attached to a posterior ring called the posterior neural arch. Two struts of bones called pedicles arise from the body and join two converging struts called laminae.

Pedicles, laminae and posterior surface of the body forms boundaries of the spinal canal. This spinal canal is the space where spinal cord passes. There is a transverse process on either side of the arch which serves as an attachment to various muscles and ligaments.

Dead posteriorly is the posterior spinous process that can be felt on our back as bumps. Posterior spinous processes also serve as an attachment to ligaments and muscles of the spine.

Adjacent to the base of transverse processes are bony projections that go superior and inferior. These are called superior and inferior articular facets and take part in the formation of facet joints. There are two facet joints between each between each pair of vertebrae one on each side. They are primarily designed to allow the vertebral bodies to rotate with respect to each other.

The lamina is a posterior arch of the vertebral bone lying between the spinous process and the pedicles [which then connect to the vertebral body completing the arch] and the transverse processes of each vertebra.

Indications of Laminectomy

• Spinal stenosis
• Sciatica
• Osteoarthritis
• Degenerative disc disease
• Herniated disc
• Ankylosing spondylitis
• Posterior Tumors

Contraindications of Laminectomy

Anterior vertebral disease

Procedure of Laminectomy

General anesthesia is used for this surgery.

Laminectomy is performed by midline posterior approach and the patient is placed prone on a spinal frame. The operative site is radiographically localized. The proposed midline incision site is marked and the surgical field prepared and draped.

The incision site is infiltrated with 1% lidocaine mixed with 1:100,000 epinephrine. The incision extent varies on the vertebrae involved. Place a midline incision after confirming the vertebral levels and marking the extent. Cut the subcutaneous in line.

The paravertebral fascia is cut on either side of the spinous process and leaving a rim of tissue between two processes intact. [Classical laminectomy removes the spinous process as well].

Retract with right-angled retractors and using sharp wide osteotomes, the paraspinal muscles are erased from the posterior part of vertebrae. The paraspinal muscles are stripped from the spinous processes using a subperiosteal technique down along the laminar to the edge of the facets either bluntly or with monopolar cautery.

Self-retaining retractors are used to widen the exposure. These also help to create tamponade effect to control the bleeding

Following adequate exposure and hemostasis, the levels to be decompressed are accurately are confirmed with the image intensifier.

In a classical laminectomy, the spinous process is removed and from thereon, the lamina is cut with a high-speed drill or rongeurs. In severe stenosis, the dura should be well protected with either instrument.

The thickened ligamentum flavum that connects the laminae of the vertebra below with the vertebra above is also removed.

For decompression of the spinal nerve, the facet joints [directly over the nerve roots] may be trimmed to provide more space to the nerve roots. This procedure is termed as foraminotomy and could be done along with the laminectomy or laminotomy.

Not more than 50% of the facet should be removed to prevent joint instability. A more extensive foraminotomy to laterally decompress the exiting nerve root will require additional removal of the superior and inferior facet complex.

Bleeding points from bone are most effectively controlled with bone wax.

Surgicel (oxidized cellulose) and Gelfoam (Gelatin) act through chemical and direct contact activation of the clotting cascade.

After adequate decompression and hemostasis is achieved, the operative site is generously irrigated with saline or lactated ringers solution, with or without antibiotics. When the dura is opened, antibiotics are avoided. The incision is then closed in layers and the skin secured with sutures, staples, or skin adhesive.

This is done on each side for each affected vertebrae.

Often the laminectomy is done as part of discectomy. In such cases, the spinous process is not removed.
In some cases, the surgeon may not want to remove the entire lamina. A small opening of the lamina above and below the spinal nerve may be able to relieve compression. [Laminotomy]

The surgery may be aided by the use of the surgical loupes or a microscope may be used at any time during the procedure.

Once the lamina and ligamentum flavum are removed the protective covering of the spinal cord (dura mater) is visible. The surgeon can gently retract the protective sac of the spinal cord and nerve root to remove bone spurs and thickened ligament. The decompression effect is generally visible on the neural tissue which is examined for any residual compression. If present, the residual compression is removed.

In selected cases, the decompression may be followed by surgical stabilization and bone grafting for spinal fusion.

After the desired surgery, the e muscle and skin incisions are closed in layers.

The following video shows a lumbar laminectomy demo.

Follow up after Laminectomy

Stitches are removed after 10-14 days. Depending upon the type and levels of surgery, the patient may be allowed to walk in immediate postoperative period or has to wait for few days.

The patient needs to avoid activities that strain the back. These could be lifting a heavy weight or household activities that require repeated or constant bending of the spine.

Complications of Laminectomy

Following complications have been associated with this procedure

• Thrombophlebitis
• Infection
• Hardware Fracture
• Implant Migration
• Spinal Cord Injury
• Persistent Pain
• Sexual Dysfunction
• Transitional Syndrome
• Pseudoarthrosis

Prognosis

Most people report measurable improvement in their symptoms after laminectomy recurrence of arthritis.

Decompressive laminectomy is successful in relieving leg pain in 70% of patients allowing significant improvement in function.

However, back pain may not be relieved and 17% of older adults need another operation. Symptoms may return after a few years.

Endoscopic laminotomy results in lesser blood loss, shorter hospital stay, and less postoperative pain drug requirement.

Smoking has been associated with poorer results.

Internal fixation of scaphoid can be done either percutaneously or using open reduction.

In modern orthopedic practice, percutaneous fixation of the scaphoid is preferred where feasible because it is minimally invasive and there is no need for wide dissection and tissue injury caused by surgical dissection.

Preoperative Planning

The fracture pattern should be clear. Conventional radiographs may not adequately demonstrate the complete fracture configuration.

A CT scan is strongly desirable if a percutaneous procedure is planned.

Read more about the anatomy of the scaphoid.

As 80% of the surface of the scaphoid is covered with articular cartilage and the scaphoid bone itself is curved, it makes it difficult to choose entry points for fixation and not many options are available.

This also means fixation device, along with the true central axis of the scaphoid, is not possible from a palmar approach

Implant

Herbert screw or headless screw is the screw used for scaphoid fixation in both percutaneous fixation and open reduction and internal fixation.

Closed reduction and Percutaneous Fixation of Scaphoid Fracture

Percutaneous fixation is largely indicated for undisplaced or minimally displaced fractures of the waist of the scaphoid.

Before starting the surgical procedure, examine the fracture pattern under the image intensifier. Be sure that the fracture is suitable for percutaneous technique, and that no secondary displacement has occurred.

The patient is placed supine and wrist is hyperextended on a bolster or rolled towel.

Hyperextension and ulnar deviation facilitates the fracture reduction and also assists in bringing the trapezium dorsal to the insertion point of the guide wire, it being at the scaphoid tubercle.

Place a rolled towel or bolster under the wrist and hyperextend it.

It may be helpful to mark on the skin the position of the scaphoid, the palmar rim of the distal radius, and the level of the scaphotrapezial joint.

A stab incision of 5 -10 mm is made distal to the scaphotrapezial joint.

Deepen through the subcutaneous tissues by blunt dissection. Then incise the capsule of the scaphotrapezial joint.

The distal pole of the scaphoid is now accessible for insertion of a K-wire.

Use a hypodermic needle to determine the insertion point radiologically before inserting the threaded guide wire.

The insertion point is on the distal surface of the scaphoid tubercle, at the edge of the scaphotrapezial joint.

Using a drill guide or protective sleeve, a threaded guide wire is inserted at the confirmed entry point directed angled 45 degrees dorsally, and 45 degrees medially, along with the mid-axis of the scaphoid.

The position of the wire should be as perpendicular as possible to the fracture line but it may not be possible in oblique fractures.

Entry is from the distal point and should not pierce the proximal cortex of the scaphoid.

In the next step, screw length is measured by either of the following methods

• Using a dedicated measuring device over the guide wire, through the drill guide. This is the preferred method.
• Take another guide wire of the same length and place its tip onto the bone at the insertion point. The difference in length between the protruding ends of the two wires indicates the length.

Subtract 2 mm to determine the screw length.

Using a power drill preferably with slow rotation. [Exerts a more controlled force on the fragments, thus reducing the risk of displacement than manual drilling] while checking the position of the tip of the drill bit using image intensification.

Use of self-tapping screws would eliminate the need for tapping, which may be carried if non-tapping screws are used.

The screw is inserted over the guide wire. The threaded section of the tip of the screw passes completely beyond the fracture plane to achieve interfragmentary compression.

Guidewire should be removed before tightening the screw.

The screw threads should be fully buried in the bone at the insertion site.

The position of the screw should be confirmed on all views using image intensification and stability of the wrist should be checked.

Open Reduction and Internal Fixation of Scaphoid Fracture

Open Reduction and Internal Fixation of scaphoid fractures is considered in fractures which are not geometrically suitable for surgery and for perilunate equivalent injuries.

In latter case, acute ligament repair is also recommended because late carpal instability invariably occurs with closed treatment.

As an urgent treatment, the carpus should be reduced as soon as possible by extending the wrist to reduce the capitate into the lunate fossa.

Open reduction is also used in fracture no-union.

Approach?

If the scaphoid has minimal comminution, this injury can be treated with a palmar Russe approach for screw fixation of the scaphoid and percutaneous pin fixation of the lunotriquetral joint.

A dorsal approach with retrograde screw fixation of the scaphoid is recommended when

• The scaphoid remains significantly displaced despite an initial closed reduction
• The lunotriquetral articulations is unstable to stress under fluoroscopy
• Comminution of the scaphoid involves a significant portion of the scaphoid waist

Dorsal approach is chosen in these cases as it provides the necessary exposure to realign the scaphoid and repair the lunotriquetral interosseous ligament.

Surgery via Palmar Approach

Palmar approach is favored for waist fractures because it protects the major vascular supply to the scaphoid.

• A  standard Russe incision along the course of the flexor carpi radialis and extended distally along the border of the glabrous skin of the thenar eminence.
• Splitting the sheath of the FCR allows it to be retracted ulnarly to protect the palmar cutaneous branch of the median nerve.
• The floor of the FCR sheath is incised longitudinally to the scaphoid, try and preserve as much radioscaphocapitate (RSC) ligament as possible because this helps to contain the proximal pole and prevent it from subluxating palmarly.
• Reduce the fracture by using dental picks/ k-wires as joysticks
• Bone grafts are used to wedge open collapsed scaphoid fractures to correct their alignment. These grafts may be taken from the iliac crest or the distal radius. The inner wall of the dorsal scaphoid cortex can be notched with a small osteotome to accommodate the wedge graft. However, the dorsal cortex of the scaphoid should be preserved as that can detach the blood supply and make the fracture highly unstable.
• Screw fixation of the scaphoid is done using the same principles as outlined above.
• Confirm the screw in the image intensifier.
• Repair palmar capsule and other layers of the wound.

Dorsal Approach

Dorsal approach is indicated in comminuted scaphoid fractures and to repair the lunotriquetral interosseous ligament.

It is important to preserve the blood supply entering with the cuff of tissue on the dorsal surface of the scaphoid just distal to the articular surface.

The dorsal approach provides better exposure for bone grafting and allows for more accurate placement of implants in small proximal-pole fractures.

• Make a straight dorsal skin incision starting over Lister’s tubercle .and extending for about 4 cm distally.  Lister’s tubercle or the dorsal tubercle of the radius is a bony protuberance on the dorsal surface of the distal radius. It separates the 2nd (ECRB and ECRL)  and 3rd (extensor pollicis longus) extensor compartments. It acts as a pulley for the EPL tendon, changing its mechanical direction of action.
• In the radial skin flap and supplies the lateral part of hand and digits, Identify and preserve the dorsal superficial branch of the radial nerve.
• Incise the extensor retinaculum over the extensor pollicis longus (EPL) tendon and open the distal part of the third extensor compartment.
• The EPL tendon is then retracted radially together with the tendons of the second extensor compartment (extensor carpi radialis brevis and longus).
• Open the capsule by a  longitudinal, or inverted T-shaped, incision, starting at the dorsal rim of the distal radius, extending to the dorsal intercarpal ligament.
• Flexion of the wrist aids in the exposure of scaphoid, especially proximal pole.
• Carry out the fixation as outlined before.

Ligament repair is carried after the scaphoid is stabilized. This may include scapholunate and/or lunotriquetral ligament.

Postoperative Care

The limb is splinted. Two weeks after surgery, the splint and sutures are removed and a short cast is applied for 1 month, at which time the cast is discontinued and a removable splint is used until the x-rays confirm union.

After that patient is put on rehabilitation protocol.

Surgery in spinal tuberculosis is considered in the patients where the disease is not responding to the drug treatment, rest and other conservative measures.

The aims of treatment of tuberculosis of the spine are:

• Control and cure of the existing ac­tive systemic and local infection and prevent its further spread.
• Achieving the stability of the spine with sound bony or strong fibrous union be­tween the involved vertebrae. Heal­ing of the lesion is implied in bony fu­sion
• Prevention and treatment of compli­cation like the neural deficit and defor­mity

Antitubercular chemotherapy is the mainstay of the treatment. Surgery is indicated in some situations in spinal tuberculosis –

• For neural complications such as paraplegia and tetraplegia.
• For kyphosis correction in active dis­ease when predicted/expected kyphosis is more than 60 degrees

How Does Surgery Help in Spinal Tuberculosis?

Surgery helps in local healing by

• Reducing the local disease load by removing the fluid abscess, granulation tissue, caseous material, sequestered bone, and disc. These are dead and de­stroyed products, and no regenera­tion of them is possible. They may not be absorbed in the natural healing, and the process may be imperfect and incomplete.
• Removes the mechanical effects of compression
• Fortifies local healing by bone grafts so that sound bony fusion between
  the involved vertebrae is achieved.
• Improves neural recovery and prevents the progression of deformity.

Types of Surgeries in Spinal Tuberculosis

Radical surgery

The bone is excised until healthy bleed­ing cancellous bone, suitable for reception of graft is achieved. In tuberculous lesion of the spine which is extensive and if all necrotic, separated, infiltrated and infracted bone is removed, it leaves behind a large gap, to be bridged by bone graft. The spine may become unstable and require fixation

Debridement Surgery

Here only pus caseous tissue and loose sequestrae are removed. The unaffected or viable bone is removed only to provide ad­equate access to the focus and to decom­press the spinal canal. Since surgical de­compression is only restricted to necrotic and separated bone, it leaves behind a relatively stable spine.

Anterolateral Decompression of the Spine

Anterolateral decompression of the spine is used in thoracic lesions and is also called extrapleural anterolateral approach is a simpler and safe technique.

Operative steps

• The patient is positioned in the lateral position
• A left-sided approach is preferred since Vena Cava is on the right side and handling of the aorta is easier than Vena Cava.
• However, the right-sided approach can be used
  • When pa­tient has already been operated from the left side and a repeat surgical decompression is per­formed
  • When the right side of the vertebral body is predominantly destroyed.
• Incision Planning
  • Minimum 3 ribs should be removed
  • The maximum number is 4 ribs
• The standard semicircular incision can be used centered over the diseased vertebra
  • If concomitant posterior instrumen­tation is planned than T incision can be used.
• Count the ribs and confirm correlation on x-ray
•  The ribs are removed subperiosteally painstakingly.
  • About 7-10 cms of ribs are removed from rib head.
• After removal of ribs, intercostal nerves are identified to define intervertebral foramina and the pedicles. The tissue in front of the vertebral body is lifted.
• The liquid pus drains out at this stage.
• The loose bone pieces, sequestrae, granulation tissues are removed and the cord is exposed
• This completes the decompression
• A rib is shaped and inserted between the two vertebrae
• The wound is closed over a drain

Benefits of the Anterolateral Approach

it is a simple safe op­eration which can be performed in any op­eration theatre and can be done on all pa­tients with consistent outcome in term of cord decompression, neural recovery, and kyphus correction.

It does not require open surgery and being extrapleural, has minimum lung problems in the postoperative period.

The postoperative morbidity is less.

References

• Jain AK, Kumar S, Tuli SM: Tuberculosis of spine (C1-D4). Spinal cord 37:362-369,1999.
• Jain AK: Treatment of tuberculosis of the spine with neurological complication. Clinical orthopaedics and related research 398:75 – 84, 2002
• Moon MS, Ha KY, Sun DH, et al: Pott’s paraplegia. Clin Orthop 323:122-128,1996.
• Rajasekaran S, Soundarapandian S: Progression of Kyphosis in tuberculosis of the spine treated by anterior arthodesis. J Bone Joint Surg 71 A:1314-1323,1989.
• Tuli SM: Tuberculosis of the skeletal system. New Delhi, Jaypee Brothers Medical Publishers LTD. 217:301.1997.
• Upadhyay SS, Seff P, Saji MJ, Seff B,Hsu LC: Surgical management of spinal tuberculosis in adults. Clin Orthop302:173-182,1994.
• Vidyasagar C, Murthy HKRS, Management of tuberculosis of the spine with neurological complications. Ann R Coll Surg Engl 76; 80-4, 1994.

Surgical approaches to the tibia are named according to the site of incision and the region accessed

Anterolateral Approach to Tibia

Indications

This incision is the classical incision for plating of tibia or open reduction of tibial fractures. The entire tibia from knee to ankle may be exposed through this incision.

It mobilizes the muscles of the anterior compartment.

Steps

• Skin  incision is 1-2 cm lateral to the tibial crest
• It can be continued distally straight over the ankle joint along the line of the anterior tibial tendon.
• The length of the incision depends on the plate length.
• The fascia is incised just lateral to the tibial crest and the dissection is carried down extraperiostally along the lateral surface of the tibia.
• Protect the long saphenous vein when retracting the skin flaps
• The periosteum mobilization may be required for exposure and mobilization of fracture edges. Rest of the periosteum should be left intact
• For exposure of the distal third of the tibia identify, protect and mobilize tibial nerve and vessels. Mobilize them from the tibial surface, along with the anterior compartment muscles.
  • At the junction of the middle and lower thirds of the tibia, the anterior tibial artery and deep peroneal nerve wrap obliquely anteriorly and distally around the lateral surface of the tibia.
    In the distal metaphyseal area, they lie on the periosteum, under the myotendinous portion of tibialis anterior, extensor hallucis longus, and extensor digitorum longus.
• The tendon sheath of tibialis anterior should remain closed if possible. If it is opened, it should be resutured so that the tendon itself is not directly under the incision.
• Close only the skin and subcutaneous tissues. Leave the fascia open to minimize the risk of compartment syndrome.

Posteromedial Approach

Indications

The posteromedial approach can be used for open plate fixation of the tibia on its posterior surface or for releasing the posterior compartment in compartment syndrome.

This approach is chosen, when direct exposure for ORIF is desired, but only the posteromedial soft tissues are safe to incise.

Steps

• Prone or supine position [in the supine position, the leg is flexed and externally rotated for exposure.]
• The incision is  made 1 cm posterior  to the medial border  of the tibia
• Subcutaneous dissection follows carefully so as to identify and/or protect the saphenous vein and nerve which are mobilized anteriorly.
• The fascia is incised in line with the skin incision
• The superficial and deep posterior compartments are mobilized. Gastrocnemius, soleus and flexor digitorum are identified and mobilized with a soft-tissue elevator, depending on the level of the fracture.
• The dissection should be done in an extra-periosteal plane.
• The approach should not be used beyond the posterolateral aspect of the tibia.
• Can expose  3/5 of the posterior tibia.
• Close the tissues barring deep fascia.
• Wound closure

Posterolateral Approach to Tibia

Indications

This approach is used in secondary bone-grafting procedures,  especially if the anterior skin condition is not suitable for surgery.

As it allows access to both the tibia and fibula and is often also used for the treatment of non-unions with posterolateral bone grafting.

Steps

• The incision begins over the lateral border of the gastrocnemius muscles and extends distally to a point that is midway between the Achilles tendon and the fibula. The length of the incision may vary
• Dissect between the superficial posterior and lateral compartments. .Starting distally, the interval between the lateral and posterior compartments is found and dissection is extended proximally.
• Incise the fascia of the gastrocnemius and soleus and mobilize them mobilized medially exposing the posterolateral aspect of the fibula is exposed.
  • Crossing perforating branches of the peroneal vessels should be ligated
• Mobilize flexor hallucis longus mobilized posteromedially and continue medial dissection until the interosseous membrane is encountered.
• Mobilize the remainder of the deep posterior compartment medialwards until the posterior aspect of the tibia is encountered.
• If incision goes way proximally, common peroneal nerve crossing the fibular neck very proximally should be protected
• In wound closure, fascia can be sutured but if there is concern about a developing compartment syndrome, the fascia should be left open and only the skin and subcutaneous layers are closed.

Incision for Closed Nailing

The entry point is established first.

• Identify the tibial crest and place a guide wire along it, extending proximally over the knee.
• The correct insertion point will be at the intersection of the guide wire with the tibial plateau.
• Make a longitudinal skin incision over the planned entry point. Extend it 3-5 cm proximally from the level of the tibial plateau.
• The incision may go either through or around the patellar tendon. Going through the tendon enables to go along the medullary canal.

If the tendon can be retracted sufficiently for direct access, this also can be used.

Minimally Invasive Approaches to Tibia

Lateral Approach

• Indications
  • For minimally invasive osteosynthesis
  • Lateral fixation with a precontoured plate (e.g. LISS plate)
• Incision
  • Proximal incision – Approximately 5 cm long, begins distal to the tibial tubercle and 1.5 – 2 cm lateral to the tibial crest curving slightly posteriorly on the proximal aspect
  • A short distal incision over the distal third of the tibia for plates longer plates is desirable to avoid vital structures being injured by a submuscular plate, or percutaneous screws.
• Incise the fascia a few millimeters lateral to the tibial crest.
• Distally, dissect the tibialis anterior tendon from the bone, preserving the paratenon.
• Retract the tendon together with the deep peroneal nerve and the anterior tibial vessels to the lateral side.
• At the proximal incision, dissect the tibialis anterior muscle from the bone without stripping the periosteum.
  Retract the tibialis anterior muscle laterally.
• Using a soft-tissue elevator, prepare a tunnel between the anterior tibial muscle and the periosteum.
• Protect the anterior tibial vessels and deep peroneal nerve distally. Depending on plate placement they should be gently retracted laterally or lifted anteromedially

Medial approach

• Preferred for distal tibial fractures.
• Make a distal incision about approximately 5 cm long, on the medial surface of the tibia. An additional incision may be required proximally for plate adjustment and screw placement
  • Distal incision could be straight or oblique depending on the need.
  • The oblique incision may increase the risk of injury to the saphenous nerve and vein, which should be identified and protected.
• Deepen the dissection to the periosteum, which is left intact.
• Use a soft-tissue elevator, or an appropriate plate, to prepare a tunnel under the subcutaneous tissues and over the periosteum.

Anteromedial Approach to Tibia

The anteromedial approach is for fractures of the distal third tibial shaft but can be used to expose the entire anteromedial surface.

It should not be used when the medial skin has a substantial contusion.

Steps

• A longitudinal incision 1-2 cm lateral to the tibial crest. Distally, continue along the medial edge of the tibialis anterior in a gentle curve in the direction of the medial malleolus.
• The deep dissection should stay superficial to the fascia layer of the anterior compartment.
• Saphenous vein and nerve, which are at risk at the distal extent of the approach.
• Avoid breaching the tibial tendon sheath should be avoided, as this can cause unwanted adhesions.
• Full-thickness skin and subcutaneous tissue flaps are then mobilized in a medial direction exposing the anteromedial aspect of the tibia

Radiation therapy is a form of cancer treatment which uses high-energy radiation such as X-rays, gamma rays, and charged particles to shrink tumors and kill cancer cells.

The radiation may be delivered by an external machine external-beam radiation therapy or by material placed in the body near cancer cells (internal radiation therapy, also called brachytherapy).

Radiation therapy is a local treatment, in contrast to chemotherapy, which is a systemic treatment affecting the whole body.

Radiation therapy may be used alone or in combination with surgery, chemotherapy, or both.

A patient may receive radiation therapy before, during, or after surgery.

How Does Radiation Therapy Work?

Radiation therapy kills cancer cells by damaging their DNA either directly or by creating charged particles or free radicals within the cells that can in turn damage the DNA.

Affected cells stop dividing and die.

Radiation therapy may be

Curative

This aims to cure the tumor or prevent recurrence after tumor removal.

Palliative

This aims to control symptoms only and there is no intent to cure the symptoms. This is done in incurable tumors.

The dose of radiation is measured in a unit called a gray [Gy] and measures the amount of radiation energy absorbed by 1 kilogram of human tissue.

The dose of radiation varies with the type of tumor and the part of the body involved.

When delivering the dose, the area selected for radiation usually includes the whole tumor plus a small amount of normal tissue surrounding the tumor to neutralize the microscopic local spread.

Types of Radiation Therapy

or from radioactive material placed in the body near cancer cells (internal radiation therapy, more commonly called brachytherapy). Systemic radiation therapy uses a radioactive substance, given by mouth or into a vein, that travels in the blood to tissues throughout the body.

External-beam

Radiation can come from a machine outside the body (linear accelerator)

It is most often delivered in the form of x-rays or gamma rays.

linear accelerator. This creates high-energy radiation that may be used to treat cancer.

Following types of external beam radiation therapy are used –

3-dimensional conformal

It uses a sophisticated computer software and advanced treatment machines for precise delivery of radiation.

Intensity-modulated

It uses collimators of devices that shape beams allowing for different areas of a tumor to receive different doses of radiation.

Image-guided

Repeated imaging like CT, MRI, or PET is performed during treatment. The computers process this information and adjust the position of the patient or the planned radiation dose, increasing the accuracy of radiation treatment.

Tomotherapy is an example which uses the machine which is a hybrid between CT imaging scanner and an external-beam radiation therapy

Stereotactic radiosurgery

Stereotactic radiosurgery is used to treat only small tumors with well-defined edges, most commonly in the brain or spinal tumors.

Proton therapy and electrons may also be used instead of photons.  Electron beams are used to irradiate superficial tumors, such as skin cancer

Internal Therapy

Internal radiation therapy is also called (brachytherapy. It delivers the radiation by placing radioactive materials inside or on the body by using delivery devices, such as needles, catheters, or some other type of carrier.

Brachytherapy may be able to deliver higher doses of radiation to some cancers than external-beam radiation therapy while causing less damage to normal tissue.

Types of brachytherapy are

Interstitial brachytherapy

This places a radiation source within tumor tissue, such as within a prostate tumor.

 Intracavitary brachytherapy

It uses a source placed within a surgical cavity or a body cavity, such as the chest cavity, near a tumor.

Episcleral brachytherapy

It is used to treat melanoma inside the eye, uses a source that is attached to the eye.

In brachytherapy, while the radioactive material is inside the body, the patient is radioactive [in contrast to external radiotherapy which does not make patient radioactive].

however, as soon as the material is removed, the patient is no longer radioactive. For temporary brachytherapy, the patient will usually stay in the hospital in a special room that shields other people from the radiation.

Systemic Therapy

A radioactive substance is ingested orally or given by an injection. For example swallowing of radioactive iodine or a radioactive substance bound to a monoclonal antibody.

Side effects of Radiation Therapy

Acute

The side effects occur during treatment and depend on the area of the body being treated, the radiation dose and the patient’s general medical condition.

These are caused by damage to rapidly dividing normal cells in the area being treated.

Examples are damage to the salivary glands or hair loss in head or neck area therapy or urinary problems when the lower abdomen is treated.

Most acute effects disappear after treatment ends, though some like salivary gland damage can be permanent.

The radioprotective drug amifostine helps to protect normal tissues from radiation during treatment.

Fatigue and nausea may occur irrespective of the part of the body treated.

Late

Depending on the area of the body treated, late side effects can include (1):

• Fibrosis
• Damage to the bowels, causing diarrhea and bleeding.
• Memory loss.
• Infertility
• Radiation exposure tumor

These adverse effects are not seen across all the patients.

References

• Gaspar LE, Ding M. A review of intensity-modulated radiation therapy. Current Oncology Reports 2008; 10(4):294–299.
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Pelvic osteotomies are done to stabilize the hip and prevent early osteoarthritis in cases of acetabular dysplasia [Altered congruency of the acetabulum resulting from its maldevelopment]. The acetabulum is the large cup-shaped cavity on the anterolateral aspect of the pelvis that articulates with the femoral head to form the hip joint.

Persistent acetabular dysplasia can lead to early degenerative joint disease whereas early recognition and treatment of persistent acetabular dysplasia can prevent that. Pelvic osteotomies realign the dysplastic acetabulum and provide a biomechanically sound hip joint. Moreover, these help to preserve the natural bone and obviate the need for hip joint arthroplasty at a young age.

Anatomy of Acetabulum

The ilium, ischium, and pubis together contribute to form the acetabulum. The three bones are initially separated by a Y-shaped triradiate cartilage that begins to fuse after puberty. The fusion is complete between 20 and 25 years of age.

An acetabular cartilage complex is a unit that is triradiate medially and cup-shaped laterally and is interposed between the ilium, ischium, and pubis. It is composed of epiphyseal growth-plate cartilage and adjacent articular cartilage.

Interstitial growth within the triradiate part of the cartilage complex causes the hip socket to expand during growth. The depth of the acetabulum increases as the result of interstitial growth in the acetabular cartilage, of appositional growth at the periphery of this cartilage, and of periosteal new-bone formation at the acetabular margin.

A spherical concavity of the acetabulum develops in response to the presence of the spherical femoral head.

Any abnormality in the position of the femoral head with respect to the acetabulum during the growth period can produce an abnormal acetabulum.

For hip osteotomies, posterior ligament anatomy is important to know and understand. These are

• Sacrotuberous ligament
• Sacrospinous ligament

Different ischial cuts have been devised around these ligaments and their mobility is important in pelvic osteotomies.

The acetabulum is supplied primarily by the periosteal arteries, with contributions from numerous local arteries.

Read more about acetabulum and hip anatomy.

Pathophysiology of Acetabular Dysplasia

Acetabular dysplasia increases the stress across the hip joint due to

• Decreased acetabular weight-bearing zone
• Increased joint reaction forces due to the lateral displacement of the center of rotation of the hip

The symptoms of acetabular dysplasia are directly related to its severity. Patients with mild acetabular dysplasia may remain pain-free for 4-5 decades of life or have vague discomfort only. Abductor lurch or a limp is may be present.

Patients with severe acetabular dysplasia have pain in the second decade of life or even earlier.

Patients activity level also affect the symptoms with severe dysplasias being less painful in nonambulatory and mild dysplasia more painful with a high level of activity.

Types of Pelvic Osteotomies

Pelvic osteotomies can be divided into two groups- reconstructive procedures and salvage procedures. These are discussed further under separate headings.

Reconstructive Procedures

These aim to realign the joint surface and produce more normal loading and to delay or prevent the development of osteoarthritis.

These are indicated in hips with

• Normal joint congruency
• No cartilage damage
• Reduce concentrically on an abduction-internal rotation

Reconstructive procedures are further of two types

• Reshaping osteotomies
• Redierctional Osteotomies

An open triradiate cartilage is a prerequisite for both types of procedures.

Reshaping Osteotomies

Reshaping osteotomies

• Change the shape and size of the acetabulum
• Done only when the triradiate cartilage is open
• Provide anterior or lateral coverage.

Additional fixation is usually not necessary, though external immobilization is often performed.

Pemberton (pericapsular) osteotomy

The Pemberton osteotomy is used for anteriorly and laterally deficient acetabula in patients older than 18 months who still have an open triradiate cartilage.

The outer iliac cortex is osteotomized, with the cut started just above the anterior inferior iliac spine and carried out posteriorly and parallel to the capsule in the direction of the triradiate cartilage.

The inner table is osteotomized if anterior coverage is necessary.

The osteotomy is opened sufficiently to bring down the anterior and lateral edges of the acetabulum.

A wedge graft is place between the fragments to maintain correction, and a spica cast is applied for 6-8 weeks.

Redislocation, sciatic nerve palsy, and femoral head osteonecrosis are known complications.

Dega osteotomy

Dega osteotomy is similar to that of the Pemberton osteotomy but the Dega osteotomy involves cutting only the lateral aspect of the ilium and thus provides posterolateral coverage. It is commonly used in dysplastic acetabula of cerebral palsy patients where it is often combined with a proximal femoral osteotomy. 

Redirectional osteotomies

These change the orientation of the acetabulum without changing the shape or dimensions. In these osteotomies, the innominate bone is completely transected, and the acetabulum is shifted as a whole into a better position.

Single innominate osteotomy (Salter)

The Salter innominate osteotomy is used to cover the anterolaterally exposed femoral head in a child over 18 months of age.

The existing acetabulum redirect and rotated through the pubic symphysis and the sacroiliac joint. The hip should be concentrically reducible and preferred age is < 6 years.

In older patients, the symphysis pubis does not remain pliable enough to allow rotation.

The osteotomy does not change the configuration of the acetabulum.

The osteotomy starts just proximal to the anterior inferior iliac spine and should exit just above the anterior inferior iliac spine.

The distal fragment is then pulled caudally and anteriorly to obtain more anterolateral coverage. A wedge-shaped graft is then inserted into the opening and fixed by 2 threaded K-wires. A single hip spica immobilization is needed.

In an unstable patient >older than 18 months, a Salter osteotomy is indicated along with an open reduction.

Kalamchi modification of the Salter osteotomy involves resecting a triangular wedge of bone from the posterior aspect of the proximal segment of the iliac bone without disturbing its far-end cortex. This provides extra stability, decreases the displacement of the distal fragment, and decreases the intra-articular pressure.

Double Innominate Osteotomy

After age 6-7 years because the stiffness of the symphysis pubis limits the mobility of the acetabulum and single innominate osteotomy is not able to serve the purpose. Here, a double innominate osteotomy is done to provide adequate coverage.

 Hopf Osteotomy

The iliac osteotomy is similar to that in the Salter procedure. A second osteotomy is performed at the medial aspect of the acetabulum through the thin isthmus between the acetabulum and the pubis. The osteotomy is subsequently fixed with 1 or 2 Kirschner wires, and a hip spica cast is applied for 6 weeks

Sutherland Osteotomy

The first cut is similar to the Salter osteotomy, and the second cut is made just lateral to the symphysis pubis. This osteotomy offers the advantage of some medialization of the hip joint and minimizes the risk of injuring the growing triradiate cartilage. An additional transverse suprapubic incision is needed though.

Triple innominate osteotomy

This osteotomy involves three cuts to further promote acetabular mobility in older children or where greater correction is necessary.

Triple innominate osteotomy include Salter osteotomy, osteotomies are made in the pubis and ischium. Different cuts are devised by different people

Steel Osteotomy

The ischium is divided at the tuberosity through a posteroinferior approach.

The ilium and pubis are then divided through an anterior approach.

This osteotomy is recommended after the closure of the ischial epiphysis.

It is not suitable for hip dysplasia secondary to neuromuscular conditions.

Because the cut in the Steel osteotomy is below the sacrotuberous and sacrospinous ligaments and these ligaments limit the mobility of the acetabulum,  it can be used in mild to moderate acetabular dysplasia only.

Tonnis Osteotomy

The difference is in the location of the ischial cut.  The ischium is accessed through a posterior approach directly over the ischial tuberosity, and the ischial osteotomy is begun proximal to the sacrotuberous ligament and directed proximally so that it exits proximal to the sacrospinous ligament.

This provides improved mobility of the acetabular fragment as the restrain of the ligaments is removed [compare with Steel].

Carlioz Osteotomy

In this variant, the ischial cut starts just below the acetabulum and runs horizontally in between the sacrospinous and sacrotuberous ligaments.

Periacetabular osteotomy of Ganz (Bernese)

This procedure osteotomizes the three pelvic bones close to the acetabulum and provides maximal freedom of rotation and tilt of the acetabular fragment in the desired position.

The osteotomy is suitable to be done  in adolescents and young adults [after the closure of triradiate cartilage]

The osteotomy, by virtue of its increased mobility, allows the surgeon to reorient the acetabulum in the sagittal and coronal planes while medializing the hip joint center, thus improving the biomechanics of the hip joint.

As the posterior column of the pelvis remains intact, immediate postoperative mobilization of the patient is possible. This procedure also maintains pelvic diameter and thus does not affect normal child delivery in female patients.

For the osteotomy, 4 cuts are made under fluoroscopy.

1. Distal to the acetabulum posteriorly toward the ischial spine
2. In the superior ramus just medial to the iliopectineal eminence, an oblique cut to assist in translating the joint medially.
3. Supra-acetabular cut is begun just distal to the anterior superior iliac spine.
4. Down the posterior column of the pelvis.

Definitive fixation is achieved with 3 or 4 threaded cortical screws

Salvage Osteotomies

Salvage procedures are indicated for relieving pain, delaying the inevitable arthroplasty and improving function in an incongruently reduced hip joint or a painful joint where redirection or reshaping osteotomies cannot be done.

These are usually done for an adolescent or adult patient with a painful, subluxated hip or for a patient with failed previous surgery.

Salvage osteotomies mainly rely on the metaplasia of the capsule to provide an extension of the articulating surface.

With increased success of Bernese periacetabular osteotomy of Ganz, the salvage surgeries may be used less commonly now.

Chiari osteotomy

The Chiari osteotomy involves osteotomy and lateral displacement of ilium that supports the femoral head with the interposed capsule.

The procedure brings the hip joint medially, in addition to expanding the contact area of the femoral head. Femoral head coverage is dependent on the width of the ilium.

The ilium is osteotomized between the capsule and the reflected head of the rectus. The osteotomy follows the capsular insertion in a curved line to the sciatic notch posteriorly and the inferior iliac spine anteriorly. The acetabulum is displaced medially by forced abduction with rotation through the pubic symphysis.

Osteotomy is fixed with threaded pins, supplemented with a hip spica cast for approximately 6 weeks. An additional shelf procedure is sometimes needed to provide adequate coverage.

Increased patient age and higher degrees of joint degeneration worsen the prognosis.

Shelf osteotomy

Shelf osteotomy or shelf acetabuloplasty provides an extra-articular buttress to prevent the subluxation of the femoral head and to expand the load-bearing area of the hip joint.

• Anterior approach, outer wall exposure only
• Identify superior acetabular edge
• Create slot 1cm deep along the edge, angled cephalad
• Remove 1 cm cortical strips from the outer table
• Insert into the slot, cutting at the desired lateral overhang
• Use remaining to fill in above slot edge
• Hold in place with reflected fascia and adductors
• Check the range of motion of the hip joint to confirm no impingement by either the femoral neck or the greater trochanter.

Indications for Pelvic Osteotomies

An abnormally shallow acetabulum can result from several causes

• Developmental Diseases of the hip
  • Developmental dysplasia of the hip
  • Slipped capital femoral epiphysis
  • Legg-Calves-Perthes disease
• Neuromuscular conditions
  • Cerebral palsy
  • Charcot-Marie-Tooth disease
  • Myelomeningocele
  • Ehlers-Danlos syndrome
  • Larson syndrome

Any condition that interferes with the relation between the femoral head and the acetabulum during the growth period can lead to acetabular dysplasia.

In general, the reduction of a unilateral hip dislocation is recommended up to 6-8 years of age.  Bilateral affected hips tend to have better function without symptoms into adulthood.

Clinical Evaluation

• Clinical history
• Physical assessment
  • Gait
  • Limp
  • Abductor lurch should be documented.
• Trendelenburg test
• Muscle wasting
• Limb-length discrepancy
• Range of motion
• Joint contracture
• Lumbar spine evaluation
• Pelvic obliquity
• Impingement test – Hip flexion followed by adduction and internal rotation to assess the abnormal femoral head-neck offset or labral damage.

Imaging

X-rays

AP view of the Pelvis with both hips in weight-bearing position

Following elements are visualized

Shenton’s Line

A continuous arc extending from the proximal medial femoral metaphysis onto the superior border of the obturator foramen. Any disruption in the continuity of this line indicates that the femoral head is proximally and laterally subluxated or dislocated.

Acetabular Sourcil

It is a dense layer of subchondral bone that normally appears as a smooth curve of uniform thickness and indicates the location of loading of the hip joint. Any side-to-side asymmetry in the thickness of the sourcil indicates abnormal focal loading.

Acetabular index of the weight-bearing zone

It quantitates the steepness of the acetabular wall or the severity of the acetabular dysplasia.

Lateral center-edge angle of Wiberg

Indicates the amount of femoral head covered by the acetabular roof.

Frog-leg lateral

The frog-leg lateral view gives a true lateral view of the proximal femur. The abnormal abutment of acetabular rim to the proximal femur may be noted.

Abduction-internal rotation views of both hips

It is essential for demonstrating a concentric reduction before the performance of a reorientation procedure.

False-profile view of the affected hip.

It is a true lateral view of the acetabulum and is done by rotating pelvis 25° towards the x-ray beam. The view indicates the anterior extent of the acetabulum covering the femoral head.

Arthrography

Arthrography is a dynamic hip study that is performed by injecting contrast medium into the hip joint and then examining the hip directly under the image intensifier. It provides a better understanding of the cartilaginous profile and a more accurate assessment of hip joint stability.

CT and MRI

Computed tomography provides a precise understanding of the pathoanatomy of acetabular dysplasia.

MRI and magnetic resonance arthrography are indicated when associated with labral pathology or cartilage damage is suspected.

How to Choose an Osteotomy for a Patient

Symptomatic medical therapy, muscle-strengthening exercises, and weight-relieving exercises can be provided initially until the execution of the pelvic osteotomy.

Selection of a particular pelvic osteotomy depends on

• Severity of the acetabular dysplasia
• Congruency of  hip reduction
• Age of the patient

General Guidelines

• In a child aged 2-10 years who has a well-reduced hip with anterolateral acetabular deficiency of a moderate degree
  • Salter or a Pemberton procedure
• Shallow, capacious, or wandering type of acetabulum
  • Pemberton
• In an older child
  • Open triradiate cartilage – Triple innominate osteotomy.
  • Closed triradiate cartilage – periacetabular osteotomy of Ganz
• Patients with an incongruent hip joint
  • If sufficient remodeling potential is present –  a Salter or Pemberton
  • No remodeling potential is left – Shelf or Chiari osteotomy [If not suited for periacetabular oseotomy]

Complications

• Injury to sciatic or femoral nerves
• Intra-articular extension of the osteotomy
• Osteonecrosis of the acetabular fragment
• Nonunion of the pubic osteotomy
• Heterotopic ossification
• Transient lateral cutaneous nerve palsy
• Painful ischial tuberosities
• Obstetric difficulties

Proximal femoral osteotomy is a joint-sparing procedure that relies on maintaining the biologic integrity of the femoral head. Once common for hip dysplasia and arthritis of the hip, proximal femoral osteotomies are performed less commonly now. But they are still used in the treatment of hip fracture nonunions and malunions and in cases of congenital and acquired hip deformities. 

For proximal femoral osteotomy, the goal is to correct the deformity and, in by doing that to realign the hip and lower extremity.

Proximal femoral osteotomies may be high cervical, intertrochanteric, greater trochanteric or subtrochanteric depending upon the location of the osteotomy.

Different Types of Proximal Femoral Osteotomy

Proximal femoral osteotomies are  of following types

Transpositional Osteotomy

The longitudinal axis of the distal fragment remains parallel to the longitudinal terminal axis of the proximal fragment.

For example McMurray osteotomy, Pauwel’s osteotomy & Putti osteotomy.

Angulation Osteotomy

The longitudinal axis of the distal fragment forms an angle with that of proximal fragment.  For example, extension osteotomy for fixed flexion deformity [in the sagittal plane] and adduction or abduction osteotomy [coronal plane].

Indications for Proximal Femoral Osteotomy

Femoral Neck Nonunion

In femoral neck nonunion, the osteotomies aim to convert vertically oriented fracture line to the horizontal so that the shear stresses at the fracture site becomes compressive to encourage osteogenesis and fracture union.

Intertrochanteric malunion

Intertrochanteric fracture malunion results in varus. Varus angulation results in shortening of the ipsilateral femur, shortening of the abductor musculature or lever arm, and often trochanteric-pelvic abutment on abduction, and a Trendelenburg gait.

In these cases, intertrochanteric osteotomy aims to realign the hip joint, restore normal abductor mechanics, and remove leg length discrepancy.

Malunion of Slipped Upper Femoral Epiphysis

If a displaced slipped epiphysis heals in situ, a fracture malunion can result. After remodeling, this malunion is characterized by coxa vara, femoral shortening, and retroversion of the femoral neck with a significant loss of hip motion.

In amenable cases, osteotomies can realign the slipped epiphysis and contain sphericity of the femoral head.

In healed cases, osteotomies aim to correct the varus, equalizes limb length and abductor tension, thereby normalizing gait.

Fibrous dysplasia

Repeated microfractures of the femoral neck lead to progressive displacement and healing of the femur in varus and the classic shepherd’s crook deformity.

Valgus-producing proximal femoral osteotomy serves to prevent progression of the deformity and the development of a fracture and reestablish a more normal femoral head–acetabular relationship.

Developmental dysplasia of the hip

Adults with developmental hip dysplasia have acetabular as well as femoral deformity.

There is valgus of the femoral neck and anteversion. The acetabulum is shallow and ill-formed.

A varus-producing proximal femoral osteotomy with derotation of the anteverted neck improves femoral head orientation.

Contraindications

• The presence of active infection
• Limitations of hip motion
• Inflammatory arthritis

Different Osteotomies Carried in Different Conditions

• Nonunion of fracture neck femur
  • McMurry’s osteotomy
  • Dickson’s osteotomy
  • Putti’s osteotomy
  • Schanz osteotomy]
• Osteoarthritis
  • Pauwel’s osteotomy
  • Mc Murray’s osteotomy]
• Unstable Intertrochanteric Fractures
  • Dimon Hughston osteotomy
  • Sarmiento’s osteotomy
• Unreduced Congenital Hip Dislocation
  • Lorenz bifurcation osteotomy
  • Schanz low subtrochanteric osteotomy
• Congenital Coxa-Vara
  • Cuneiform osteotomy by Fish
  • Pauwel’s Y osteotomy
  • Basilar osteotomy
• Leg Calve Perthes Disease
  • Varus de-rotation osteotomy
• Avascular Necrosis of Femoral Head
  • Sugioka – Trans trochanteric osteotomy
  • Varus de-rotation osteotomy

Evaluation of the patient for Proximal Femoral Osteotomy

• Complete clinical evaluation

  • Extent of deformity
  • Planes of deformity
  • The range of motion of both the hips
  • Any hip or knee contracture
  • Limb-length discrepancy
  • Previous incisions, skin quality,
  • Any signs of the previous infection

• Lab Studies

  • CBC
  • ESR
  • CRP
  • Routine preoperative blood work

• Imaging

  • Standing anteroposterior pelvis radiographs
    • Neck-shaft angle
    • Hip joint integrity.
  • Lateral View
    • Sagittal deformity.
  • Computed tomography/MRI
    • Confirm the presence of a nonunion.
    • For osteomyelitis.

Procedure of Proximal Femoral Osteotomy

• The patient is operated on a radiolucent fracture-table so as to have intraoperative fluoroscopic control
• The approach and site of osteotomy would depend on the indication for osteotomy and the osteotomy planned. Often, with internal fixation, the lateral approach is used.
• The procedures for different osteotomies are discussed separately
• External fixation is typically reserved for low intertrochanteric or subtrochanteric osteotomies.

Complications

Major complications of a femoral osteotomy include the following:

• Infection
• Neurovascular injury
• Nonunion
• Inability to obtain or maintain a full correction
• Chronic postoperative pain
• Deep vein thrombosis
• Painful hardware
• Joint stiffness

Important osteotomies of the proximal femur

 Mcmurray’s  Displacement Osteotomy

This osteotomy is mostly done in treating non-union of trans-cervical fracture neck femur and occasionally in osteoarthritis of the hip.

The aim is to make the fracture line more horizontal and thus convert shearing forces to compressive to promote union.

Thus, McMurray’s osteotomy allows painless weight bearing even in presence of persistent non-union which is a marked advantage over angulation osteotomy.

Since the distal fragment is placed directly under the head of the femur, weight transmission occurs from the head to the distal shaft fragment bypassing the fracture site. Hence even if the fracture does not unite, painless weight bearing is possible.

In Mcmurray’s osteotomy, distortion of proximal femoral anatomy can compromise a replacement in the future and should be taken into consideration.

The osteotomy starts below the level of lesser trochanter laterally and proceeds in an oblique manner to exit proximal to the lesser trochanter medially.

The lower fragment is displaced medially by manual pressure and abduction so that it is placed under the head of the femur.

Cancellous screws or Smith-Peterson nail in conjunction with Tupman plate are commonly used fixation devices.

Postoperatively, the patient is mobilized as soon as symptoms permit and is put on physical therapy, starting with touch-down weight bearing until union occurs. Once union occurs, unrestricted rehabilitation is possible.

Schanz Angulation Osteotomy

This is a valgus osteotomy where the shaft is set into abducted position so that the shearing stress of weight bearing and muscle retraction becomes an impaction force.

It is done in cases of non-union of fracture of neck of femur and congenital dislocation of the hip.

The femur is cut transversely at ischial tuberosity level & the proximal fragment is adducted until it rests against the side wall of the pelvis.

This lengthens the distance of the gluteus medius and provides a fulcrum so that adequate leverage of the muscle is obtained.

The position is maintained by plate fixation.

 Pauwel’s Varus Osteotomy

Varus femoral osteotomies are designed to elevate the greater trochanter and move it laterally to restore joint congruity and decrease the force acting on the edge of the acetabulum moves to the middle of the weight-bearing surface.

The osteotomy is indicated in antalgic abductor limb, abduction deformity, painful adduction, and valgus neck-shaft angle.

Varus osteotomy shortens the limb to some degrees and increases the prominence of the greater trochanter. It also results in overloading of the medial compartment of the knee.

Pauwels Valgus Osteotomy

Valgus intertrochanteric femoral osteotomies transfer the center of hip rotation medially from the superior aspect of the acetabulum to decrease the weight bearing area of the femoral head.

It is not done in

• Hips with flexion of less than 60°
• Knock knees as this will increase the deformity at the knee.

Sugioka Transtrochantric Rotational Osteotomy

This is done for osteonecrosis to prevent progressive collapse of the articular surface and to improve the congruity of the hip joint.

To do this the femoral head and neck segment is rotated anteriorly around its longitudinal axis, through a trans-trochanteric osteotomy.

So that the weight-bearing force is transmitted to the posterior articular surface of the femoral head, which is not involved in the ischemic process.

Postoperative skin traction is given for 2-3 weeks an active range of motion exercises of the hip are begun at 10-14 days.       

Cuneiform Osteotomy of Femoral Neck

 The osteotomy is recommended in cases of slip greater than 30 degrees.

After exposure, adjacent to the epiphyseal plate, a wedge-shaped piece of bone is removed with its base directed anteriorly and superiorly with apex posteroinferiorly.

The epiphysis is reduced by flexion, abduction and internal rotation of limb, taking care to put much tension on the posterior periosteum, capsule and vessels.

 Dimon-Hughston Osteotomy

It is a medial displacement osteotomy used in altering the pathologic anatomy of the unstable intertrochanteric fracture to convert that to a stable, albeit nonanatomic position.

The procedure involves

• Transverse osteotomy of the proximal femoral shaft at the level of the lesser trochanter
• Osteotomy and proximal displacement of the greater trochanter and the attached abductor muscles
• Medial displacement of the femoral shaft
• Impaction of the proximal fragment into the medullary canal of the femoral shaft. If the proximal fragment is firmly impacted into the femoral shaft, a stable construct will result.

Sarmiento osteotomy

It is a valgus osteotomy for unstable intertrochanteric fractures to provide a medial cortical buttress.

This technique involves

• Oblique osteotomy of the proximal femoral shaft, extending from the base of the greater trochanter to a medial position, 1cm distal of the apex of the fracture surface
• Implant placement into the proximal fragment, 90.degre to the fracture surface
• Reduction and impaction of the osteotomy

Outcomes of Proximal Femoral Osteotomy

When proximal femoral osteotomy is used for the correction of congenital/acquired deformities and repair of hip fracture nonunion, results have been favorable. Hip range of motion, gait, pain, leg-length discrepancy and patient satisfaction are improved.

With regard to the use of proximal femoral osteotomy in the nondeformed hip with osteoarthritis, long-term follow-up reveals that many patients go on to require total hip arthroplasty.

An osteotomy is a surgical procedure where the bone is cut to change its length or alignment. Often the procedure is done in an attempt to correct an abnormality that has resulted from trauma or disease.

The procedure is able to correct the following deformities.

• valgus/varus angulation
• anterior/posterior angulation
• internal/external rotation
• lengthening/shortening
• medial/lateral shift
• dorsal/ventral shift

An osteotomy corrects the biomechanical alignment of the extremity, increases the contact area or improves joint congruence and restores the biomechanical advantage.

Indications for Osteotomy

Growth Discrepancy

Growth disturbances may be caused by trauma, disease, or genetic predisposition, often due to the premature closure. This is especially a problem in forearm and legs where two bones are present. The unaffected bone continues to lengthen while the damaged bone lengthens at a slower rate, the normal bone will be forced to bow away from the shortened bone leading to deformity and altered joint orientation.

Osteotomy is necessary to straighten the deformity and return the limb to a normal function and appearance.

Similarly, trauma a portion of a growth plate may result in a selective slowing or cessation of growth on that side while growth is normal on the unaffected side of the same bone. For example, trauma to the lateral side of the distal radial physis results in valgus deformity if the wrist. Osteotomy through the site of maximal deformity is necessary to return the bone to the normal anatomical position.

Deformity following Malunion

Diaphyseal and metaphyseal fractures may unite in malposition resulting in angular, rotational, or shortened positions requiring osteotomy.

Rotational Deformities

These may occur following trauma or due to a congenital condition such as tibial torsion. Osteotomy may be necessary in severe cases affecting limb function.

Limb Length Discrepancy

In limb lengthening surgeries,  osteotomy may be performed so as bone ends could be distracted by using hardware like Ilizarov external fixator.

Dysplasia Correction

For example in hip dysplasia. Usually performed early before setting in of arthritic changes.

Contraindications

• Neuropathic Arthropathy
• Inflammatory Arthropathy
• Active Infections
• Severe Osteopenia
• Advanced Arthritis

Principles

• Accurate alignment and reduction of the osteotomy gap must be accomplished
• Rigid fixation, using internal fixation or external fixation must be provided
• Soft tissues must be carefully protected

Planning of the Procedure

It is important to plan the procedure to minimize any chance for error.

Preoperative radiographs in at least two views should be taken of both the affected bone or bones and the normal unaffected contralateral limb. Radiographs must include the entire joint above and below the deformed bone. Rotational deformity can be missed on radiographs and should be measured clinically.

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

Amount of bone resection, angle and plane of osteotomy should be well planned by preoperative drawings.

Types of Osteotomies

Transverse

It is ideal for correction rotation alone in the metaphyseal and diaphyseal region.  The procedure is performed at the area of major rotation by cutting a transverse plane through the bone.  When the transverse osteotomy technique is employed, the fixation is very stable.

Oblique

Oblique osteotomy allows two bones to be separate or lengthened and still allow for point contact. It can also be used to provide rotational correction as well by placing the proximal obliquity into 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, wedge osteotomy is used primarily to correct angular deformity, but may be used for angular and rotational problems if both exist simultaneously.

It is of following types

Open Wedge

The cut is made at the desired site and a bone wedge is inserted on the concave surface. It results in bone lengthening.

Closing Wedge Osteotomy

A predetermined size of the wedge of bone is removed from the point of maximal deformity with the base of the wedge is at the convex surface of the deformity. The gap is then closed, correcting the angulation and fixed. It results in slight bone shortening.

Fixation of Osteotomies

Osteotomies can be stabilized using all conventional forms of internal or external fixation.

It could be

Internal fixation – plating, screws, K-wire fixation, tension band wiring

External fixation – Tubular fixator, Ilizarov fixator