Oblique Closing Wedge Osteotomy Research Articles

Oblique Dorsiflexion Osteotomy of the Distal Tibia for Fixed Ankle Equinus: Surgical Technique.

There are significant challenges in the treatment of a severe rigid ankle equinus caused by a flat-topped talus, arthrogryposis, burn sequelae, or extensive scarring. Conventional approaches, such as soft tissue releases, often fail due to joint incongruence or compromised soft tissues, thereby necessitating supramalleolar osteotomies. The classic transverse supramalleolar osteotomy (TSO) of the distal tibia can lead to secondary anterior translation of the centre of rotation of the ankle and alters mechanical and anatomical axes. An alternative technique involves an oblique closing wedge osteotomy of the distal tibia, with a fulcrum near the ankle joint. This technical note delineates the planning parameters and procedural steps for the oblique dorsiflexion osteotomy of the distal tibia (ODODT). Using an anterior approach to the distal tibia, the "alpha angle," which determines the size of the closing wedge required for the foot to be plantigrade, is resected with a fulcrum at the most posterior part of the ankle joint, ensuring that the posterior cortex remains intact. The inclination of this resected wedge is planned preoperatively and is referred to as the "beta angle." This aims to equalise the lengths on both sides of the osteotomy. For osteotomy fixation, 2 or 3 cannulated screws in lag mode are employed. Postoperatively, a short cast boot is used for 6 weeks. The ODODT is a salvage solution for severe rigid ankle equinus when first-line foot and ankle procedures are impractical due to tibiotalar incongruence or poor soft tissues. Advantages include minimal translation of the centre of rotation of the ankle, excellent stability when the posterior cortex remains intact, avoidance of large internal fixation devices, and cost-effectiveness, making it suitable for low-resource settings. Olleac R, Farfan F, Acosta L, et al. Oblique Dorsiflexion Osteotomy of the Distal Tibia for Fixed Ankle Equinus: Surgical Technique. Strategies Trauma Limb Reconstr 2024;19(2):104-110.

Osteotomie am distalen Femur zur Korrektur von Genu valgum und Torsionsfehlern

Femoral medial closing wedge osteotomy for the correction of valgus malalignment to unload the cartilage in the lateral compartment and/or correction of symptomatic torsional malalignment. Lateral unicompartmental osteoarthritis of the knee with genu valgum in young patients. Symptomatic torsional malalignement of > 30° and < 0°. Grade 3 and 4 cartilage damage in the medial compartment. Heavy smoking. Medial meniscectomy. Extreme obesity. Inadequate soft tissue conditions. The operation begins with arthroscopy of the knee joint. In case of grade 4 lateral cartilage damage, a microfracture is performed. The distal femur is exposed via an anteromedial longitudinal incision starting 10 cm above the patella and ending in the upper third of the patella. The medial femoral cortex is exposed using Hohmann retractors and an oblique closing wedge osteotomy is performed with an oscillating saw. In case of valgus correction, the lateral cortex is left intact. In case of correction of torsional malalignment, the osteotomy plane is horizontal and the lateral cortex is cut. The wedge height is determined preoperatively based on full leg x-rays. The leg axis is controlled intraoperatively with a long metal rod and the use of an image intensifier. The osteotomy is manually closed and stabilized with a locking plate. The patient is mobilized under load with 20 kg body weight for the first 6 postoperative weeks. Full range of motion is permitted. We treated 23 patients with lateral cartilage damage (grades 3 and 4) and genu valgum with medial closing osteotomy of the distal femur (6 men and 17 women). After 3.5-years follow-up, the KOOS increased from 48.4 points to 84.9 points. In one case, there was an early loss of correction, with subsequent revision with bone grafting and lateral osteosynthesis. No peri-or postoperative complications such as infection, thrombosis, and embolism occurred. In 5 cases a torsional osteotomy was performed. The torsional osteotomy was performed 4 times due to chronic patellofemoral instability, and once due to a medial tibiofemoral instability. Healing complications were not observed in this population. Recurrent instability was not observed.

Tibia Vara Deformity After Below Knee Amputation and Synostosis Formation in Children

Progressive varus deformity of the tibia in pediatric patients after transtibial and Syme amputations has not been reported in a series. A distal tibia to fibula synostosis, created surgically to minimize the risk of terminal overgrowth or occurring spontaneously, was noted in most patients. The goals of this study are to address the causes of the deformity, the implications for prosthetic wear, and potential treatment options. Twelve patients identified from the juvenile amputee database at 2 centers developed progressive varus deformity of the residual limb. One patient had bilateral involvement. A distal tibia-fibula synostosis was noted in 12 (92%) of the residual limbs, and in one, a fibrous union was suspected. The level of amputation was trans-tibial in 10 patients, and Syme amputation in 3 patients. Two patients had acquired trans-tibial level of amputation from congenital constriction band syndrome. Nine of the patients (75%) were between the ages of 3 and 5 years at the time of injury. The mean proximal medial tibial angle was 80.5 degrees (range, 75-85 degrees). Ten of the patients underwent procedures to correct the mechanical axis and resolve or prevent problems with prosthetic fitting. Four patients has proximal tibial osteotomies (HTO), 2 oblique closing wedge osteotomies, 1 shaft osteotomy, and 4 lateral proximal tibial hemi-epiphyseodesis. In 2 patients, no correction was recommended. The presence of a distal tibia-fibula synostosis in pediatric amputee patients may contribute to the risk of developing a progressive varus deformity and should be monitored during a child's growth. Distal tibiofibular synostosis may disrupt normal differential longitudinal growth and may contribute to this progressive angular deformity. Severe deformity may require prosthetic modifications or operative correction to provide for a normal mechanical axis. Lateral hemiepiphyseodesis of the proximal tibia can be effective if the deformity is detected early. We do not recommend creation of a synostosis in the young child for terminal growth. Level 4.

Oblique Closing Wedge Osteotomy and Lateral Plating for Cubitus Varus in Adults

Corrective osteotomy around the elbow can require longer recovery time in adults than in children because of the longer healing period and the propensity for stiffness. We hypothesized a lateral oblique closing wedge osteotomy with a larger contact area and fixation with a lag screw plus early motion would provide stable fixation and early motion recovery in adults with cubitus varus deformity. Twelve consecutive patients who needed surgery were treated using this procedure. They were allowed active motion exercises 1 week postoperatively. The age of the patients at the time of surgery averaged 39 years (range, 31-48 years). The minimum followup was 15 months. All patients achieved healing of the osteotomy, and regained preoperative arcs of elbow motion at a mean of 7.3 weeks (range, 2-12 weeks) postoperatively. The average humerus-elbow-wrist angle improved from -23.3 degrees to 8 degrees (p < 0.002) by a mean gain of 29.6 degrees . The mean lateral prominence index did not increase postoperatively. The final MEPI and DASH score averaged 95.4 points and 5.5 points. No patient experienced nerve palsy. Oblique osteotomy and fixation with a lag screw and lateral plating is a reasonable alternative technique for cubitus varus in adults, with early recovery of elbow motion and satisfactory deformity correction. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Inherent stability of proximal first metatarsal osteotomies: A comparative analysis

Proximal first metatarsal osteotomies have been criticized for their instability leading to the dorsal displacement of the first metatarsal head. The purpose of this study was to compare inherent stability of fixated proximal oblique wedge and crescentic first metatarsal osteotomies against simulated vertical ground reactive forces. The authors evaluated four groups of 10 models each with various proximal osteotomy and fixation configurations. Group I was a control group of bone models without osteotomies; group II had oblique closing wedge osteotomies with one 2.7-mm, fully threaded, cortical screw fixation; group III had oblique closing wedge osteotomies with two 2.7-mm, fully threaded, cortical screw fixation; and group IV had proximal crescentic osteotomies with one 4.0-mm, partially threaded, cancellous screw fixation. All 40 bone models were stressed with simulated vertical ground reactive forces. Maximum load to achieve catastrophic failure was higher in the crescentic group (67.7 N, SD 15.1 N, p < or = .005), but the energy required to displace the osteotomy during the stressing sequence was higher in the two-screw oblique closing wedge osteotomy (390.6 N.mm, SD 153.4 N.mm, p < or = .01). The single-screw oblique closing wedge osteotomies showed the least ability to resist simulated vertical ground reactive forces (39.6 N, SD 19.1 N, p < or = .005).