Oblique Osteotomy Research Articles

Sequential Dissection for Exposure of the Second Metatarsophalangeal Joint

Instability of the second metatarsophalangeal (MTP) joint is relatively common, and although the anatomy of the joint has been well described and plantar plate pathology has been identified, little has been written about its exposure and repair. The goal of this study was to elucidate the necessary dissection to expose and potentially repair the lesions of the plantar plate through a dorsal approach. Sequential dorsal dissection of the second MTP joint was carried out in eight cadaveric specimens. After each step, measurements were obtained using fluoroscopic imaging and digital photography to determine the amount of exposure of the plantar plate gained by each step. Dorsal capsulotomy of the second MTP joint with collateral ligament release off of the proximal phalanx base, then combined with a subcapital oblique metatarsal osteotomy provided on average 8 and 8.5 mm of exposure of the plantar plate as measured by digital photography and fluoroscopy, respectively. Minimal exposure was gained by releasing the collateral ligaments from the metatarsal head or elevating the plantar plate off of the plantar metatarsal head. Exposure of the plantar plate can be obtained by releasing the collateral ligaments off of the proximal phalanx and performing a subcapital oblique osteotomy. Minimizing the risk of disrupting the blood supply to the metatarsal head may be possible by avoiding collateral ligament or plantar plate release.

Hemiarthroplasty and Distal Oblique First Metatarsal Osteotomy for Hallux Rigidus

In a retrospective study, we evaluated the effect of the addition of a decompressive osteotomy to hemiarthroplasty of the great toe in terms of clinical and radiographic outcomes. Twenty-one consecutive patients affected by Grade III hallux rigidus underwent distal oblique osteotomy of the first metatarsal and hemiarthroplasty of the hallux metatarsophalageal joint. Clinical evaluation included the American Orthopaedic Foot and Ankle Society scoring system (AOFAS) and the Short Form 36 questionnaire (SF-36), preoperatively and at followup visits. Standard weightbearing radiographs were performed to assess implant alignment, loosening, and bone loss. The mean followup was 26.4 (range, 16 to 29) months. The mean AOFAS score improved from 47.5 ± 11.5 preoperatively to 76.0 ± 15.5 postoperatively (p < 0.01). At the last followup the SF-36 subscales Physical functioning, Bodily pain and Emotional role scores were increased from baseline. At the last followup, six patients (28.5%) were very satisfied with the outcome, ten patients (47.6%) were satisfied and five patients (23.8%) were dissatisfied. In the dissatisfied group, two patients had persistent joint pain with stiffness and subluxation of the prosthesis. Dorsal subsidence of the implant was present in ten patients at the last radiographic followup. Hemiarthroplasty of the proximal phalanx and distal oblique metatarsal osteotomy for Grade III hallux rigidus at 2-years followup yielded mixed patient satisfaction and unsatisfactory radiographic outcome.

Posterior trochanteric osteotomy provides adequate exposure for treatment of acetabular fractures

Objective To explore whether posterior trochanteric osteotomy can provide adequate exposure to facilitate surgery for acetabular fractures.Methods From January 2000 to January 2008, 32 cases of acetabular fracture involving the acetabular dome underwent posterior trochanteric osteotomy for a better exposure to facilitate internal fixation with acetabular tridimensional memory fixation system(ATMFS).Of the 32 cases, 28 were followed up.They were 16 men and 12 women, with a mean age of 39.9 years (16 to 73) .There were 19 fresh fractures and 9 old ones.Results Twenty-eight cases were followed up for an average of 48.9( 19 to 95) months .According to Matta criteria, anatomical reduction was achieved in 17 cases, satisfactory reduction in 10 cases, and unsatisfactory reduction in one old fracture.All the fractures got direct bony union with no displacement or deep infection.All the osteotomy fragments healed within 14 weeks without any nonunion, proximal migration, loosening or breakage of hardware or deep infection.Superficial infection occurred in one patient but healed after regular dressing.Two patients had to sustain removal of the implants from greater trochanter because of irritation.According to the Medical Research Council (MRC) grading system, the strength of the abductors was of Grade 4 in 3 patients, of Grade 3 in one patient and normal in the rest.By the modified d'Aubigne & Postel scoring system, the excellent to good rate was 89.3%.Conclusion Posterior trochanteric osteotomy can provide an adequate exposure of the acetabular dome without such complications as nonunion, proximal replacement or weakness of the abductors which often occur after the conventional oblique osteotomy. Key words: Acetabulum; Fractures; Osteotomy; Fracture fixation, internal

Hemicallotasis for correction of varus deformity of the proximal tibia using a unilateral external fixator

BackgroundGradual correction of varus deformity of the proximal tibia is generally accepted and produces good results. However, most studies have used circular external fixators, which are complex and cause patient discomfort. This study was undertaken to determine the efficacy of hemicallotasis with a unilateral external fixator for correction of varus deformity of the proximal tibia. MethodsThirteen patients (21 legs, 8 bilateral) were included in this study: 6 with constitutional bowing, 3 with a malunion, 2 with Blount's disease, and 2 with Turner syndrome. There were 7 males and 6 females of mean age 21 years (range 13–40). With an oblique osteotomy on the proximal tibia, a unilateral external fixator was placed on the medial side. Using a distraction of 1 mm/day, the external fixator was removed after consolidation of the callus. ResultsSurgery corrected medial proximal tibia angle from a preoperative average of 75.1° (64°–81°) to 88.6° (86°–90°) at final follow-up. Average tibiofemoral angle improved from −7° to 6.8°. The duration of external fixation averaged 101.3 days and the external fixation index was 70 days/cm. No patient had a limited ambulation, and all recovered preoperative range of knee motion (mean 130.1°) at final follow-up. Seven minor complications (pin tract infection, clamp loosening) and 1 major complication (uncorrected genu procurvatum) were observed. ConclusionsHemicallotasis using a unilateral external fixator was found to be a safe and simple corrective procedure for varus deformity of the proximal tibia, with few complications.

Radiographic evaluation of osteotomized ulnar segments following arthroscopic treatment for canine medial coronoid disease

To assess movement of ulnar segments radiographically, following proximal and midshaft ulnar osteotomy or ostectomy after arthroscopic treatment for dogs diagnosed with medial coronoid disease. Fragmentation and cartilage wear were treated arthroscopically and the presence of incongruity confirmed. Osteotomies were performed at the mid-point or proximal third of the length of the ulna. The distance of separation between the ulnar segments and the adjacent radius were measured and followed by serial radiographs postoperatively until healing had occurred. Proximal oblique osteotomies located at one-third the length of the ulna were associated with the most movement of the ulnar segments, most notably of the proximal segment. Osteotomies or ostectomies performed in the middle demonstrated less segmental movement and on average, slightly longer time to heal. Movement of the ulnar segments in both groups occurred immediately, and then peaked at two to four weeks postoperatively, tending to plateau thereafter. Radioulnar incongruity is considered a facet of the aetiopathogenesis of canine medial coronoid disease. This creates abnormal loads and focal wear along the medial coronoid process. Performing an oblique osteotomy at a location measured at the proximal third of the length of the ulna allows increased movement of the proximal segment, which may result in unloading of the medial compartment. Performing an osteotomy or ostectomy distally dampens segmental movement due to constraint of the interosseous ligament. These findings suggest that a proximal oblique osteotomy at this location creates immediate favourable movement with low morbidity.

Direction of the oblique medial malleolar osteotomy for exposure of the talus

IntroductionA medial malleolar osteotomy is often indicated for operative exposure of posteromedial osteochondral defects and fractures of the talus. To obtain a congruent joint surface after refixation, the oblique osteotomy should be directed perpendicularly to the articular surface of the tibia at the intersection between the tibial plafond and medial malleolus. The purpose of this study was to determine this perpendicular direction in relation to the longitudinal tibial axis for use during surgery.Materials and methodsUsing anteroposterior mortise radiographs and coronal computed tomography (CT) scans of 46 ankles (45 patients) with an osteochondral lesion of the talus, two observers independently measured the intersection angle between the tibial plafond and medial malleolus. The bisector of this angle indicated the osteotomy perpendicular to the tibial articular surface. This osteotomy was measured relative to the longitudinal tibial axis on radiographs. Intraclass correlation coefficients (ICC) were calculated to assess reliability.ResultsThe mean osteotomy was 57.2 ± 3.2° relative to the tibial plafond on radiographs and 56.5 ± 2.8 on CT scans. This osteotomy corresponded to 30.4 ± 3.7° relative to the longitudinal tibial axis. The intraobserver (ICC, 0.90–0.93) and interobserver (ICC, 0.65–0.91) reliability of these measurements were good to excellent.ConclusionA medial malleolar osteotomy directed at a mean 30° relative to the tibial axis enters the joint perpendicularly to the tibial cartilage, and will likely result in a congruent joint surface after reduction.

Ulnar shortening osteotomy: are complications under reported

Introduction Ulnar shortening osteotomy has become an accepted treatment for a variety of ulnar sided wrist disorders. We have been performing ulnar shortening with an oblique osteotomy cut with the aid of a commercially available jig. The osteotomy is then fixed with a Dynamic Compression Plate. The aim of this study was to report the complications following ulnar shortening. Methods We retrospectively analysed 56 consecutive ulnar shortening osteotomies. There were 36 female and 19 male patients. The mean age was 45 years. The mean follow-up was 399 days. 25 patients had pre-operative MRI scans and in 34 arthroscopy of the wrist had been performed. 22 tears of the triangular fibrocartilage complex were recorded on arthroscopy. In all cases shortening had been performed with the aid of a jig and bone resection performed in an oblique orientation. Dynamic Compression Plates were used for fixation and a lag screw was inserted through one of the plate-holes and across the osteotomy site. Radiographs were evaluated for pre-operative and post-operative ulnar variances and post-operatively for bony union. Results The average post-operative ulna variance was 0.12mm. The average time for osteotomy union was 82 days. There were four delayed unions. There were three non-unions. The average time of revision surgery was ten months. All cases have gone onto radiographic union. 19 patients underwent a second operation to have their plates removed. Average time to plate removal was 494 days. There were two cases of re-fracture following plate removal. Conclusion The rate of delayed and non-union following ulnar shortening osteotomy is higher in our series when compared to the literature. We also noted a higher incidence of plate removal and re-fracture through the osteotomy site. These complications are under-reported in the literature and more emphasis should be given when consent is taken for this procedure.

Rhizarthrose débutante et rotation du bloc articulaire trapézométacarpien en îlot sur le pédicule radial. DOOR procedure

Introduction Trapezium dysplasia and trapezo-metacarpal joint instability induce TMC-joint arthritis. To correct these two factors, we propose a surgical technique associating a double oblique osteotomy of the trapezium and of the first metacarpal basis, and an island rotator transfer of the TMC-joint harvested in block on the radial pedicle. The articular block is rotated at 180° on the longitudinal axis of the thumb. Method Since 2000, 41 cases were performed on 38 patients (35 women, three men). Mean age was 47 (from 17 to 63). All the patients complained of a painful thumb and sometimes of instability. The mobility was preserved (Kapandji 9/3). The grasp was 43% of the opposite side. X-rays showed a TMC-joint instability in all the cases. Results DOOR procedure was possible 41 times. With a mean follow-up of 65 months (from three months to ten years), 28 thumbs are pain-free, nine patients complain of barometric pain or pain after heavy works. Four thumbs were reoperated after failure of the procedure. Mobility decreased (Kapandji 8/2), the grasp increased to 100% of the opposite side. The joint was stabilized in all the cases. X-rays showed an osteolysis in three cases. The cartilage was worse in 19 cases, improved in five cases, stable in 14 cases. Discussion DOOR procedure is a very demanding procedure but reliable. The correction of the dysplasia is constant. Denervation could explain the good clinical results in cases of joint narrowing. Conclusion DOOR procedure is a solution in cases of trapezium dysplasia associated with instability and early stages of osteoarthritis in young women.

Mini Locking Plate as “Medial Buttress” for Oblique Osteotomy for Hallux Valgus

Level of Evidence: V, Expert Opinion

Type IV-D thumb duplication: A new reconstruction method

In the Wassel type IV classification category, the thumb is duplicated from the metacarpophalangeal joint; this abnormality accounts for approximately 50% of the cases of thumb duplication. Type IV is divided into four subtypes in which the IV-D type, or convergent (9% of cases), is the most complex form because both thumbs are hypoplastic with a divergent metacarpophalangeal joint and a convergent interphalangeal joint. Reconstruction is prone to axis deformity and ligament laxity, whereas the Bilhaut-Cloquet technique's main pitfall is nail dystrophy. We propose a modified Bilhaut-Cloquet procedure to avoid these complications. Four males (mean age: 11 months; range: 10-12months) with IV-D thumb duplication were operated on using a modified Bilhaut-Cloquet procedure. The skin is preliminarily marked, taking into account the excision of the central skin and the more hypoplastic nail of the two (most often the radial nail). Both proximal phalanges are split longitudinally and the central halves discarded. An oblique osteotomy is performed at the base of the distal phalanx of the ulnar thumb duplicate (the less hypoplastic) and the radial wedge is excised. The same osteotomy is applied to the distal phalanx of the radial thumb duplicate, but the radial wedge is preserved. The proximal phalanx and the bases of the distal phalanx are joined by bone suture. Axis correction and ligament stability are thus achieved without nail surgery. The patients were examined with a mean 24months of follow-up (range: 12-36months). The result was good in all four cases according to the Horii score. This procedure combines an excision of the central part of the proximal phalanx and partial excision of the base of the distal phalanx. It provides axis correction and stabilization of the interphalangeal joint while avoiding subsequent nail dystrophy because a single nail is preserved. Preliminary results are encouraging: no axis deformity, instability or nail dystrophy has been noted. Nonetheless, the long-term results need to be evaluated. IV retrospective study.

The oblique wedge osteotomy of the metacarpal condyle for reconstructing wassel type IV thumb duplication in older children and adults

In reconstructing the Wassel type IV thumb duplication in infants, a deviation deformity of the retained thumb may be corrected by a closing transverse wedge osteotomy of the metacarpal neck. In older children and adults, this technique may cause avascular necrosis of the retained metacarpal condyle. We have addressed this problem by using an oblique wedge osteotomy of the metacarpal condyle. Ten patients (mean age, 18.9 years) underwent this procedure between 1993 and 2007. Patients with deviation angles of 30° or less had a closing wedge osteotomy, while those with deviation angles exceeding 30° had a rotational bone graft osteotomy. Deviation angles were corrected from a mean of 32° (range, 16° to 55°) to 0° in eight thumbs and 10° in two thumbs. There were no cases of avascular necrosis. All patients achieved good results by Tada's criteria. This technique effectively restores bony alignment of the thumb and preserves vascularity of the retained condyle.

Hallux Valgus Correction in a Patient with Metatarsus Adductus with Multiple Distal Oblique Osteotomies

Metatarsus adductus is a structural foot deformity that is rarely associated with hallux valgus deformity. Surgical treatment is challenging, and multiple osteotomies are often required to correct both deformities. However, surgical impact must be considered, especially in elderly patients. We present a clinical case of a 76-year-old woman affected by hallux valgus and metatarsus adductus deformity. Multiple distal oblique osteotomies were performed on the first, second, and third metatarsals, coupled with Z-lengthening of the extensor digitorum longus tendons.

Oblique Osteotomy and Coronoidectomy in Extreme Prognathism of Apert Syndrome

We report a case of oblique osteotomy and coronoidectomy for correction of extreme prognathism in Apert syndrome.A 16-year-old girl presented with a prognathic mandible. A prototype model was formed using computed tomography. After a mock bilateral oblique osteotomy of the mandible, the distal segment did not overlap the proximal segment, and it caused bony impingement between the coronoid process and the subcondyle of the proximal segment. An oblique osteotomy of the mandible was done through a submandibular approach, and bilateral coronoidectomy followed. After surgery, mandibular parameters were reviewed. The mandibular plane-Frankfort horizontal (MP/FH) angle decreased from 44 to 11 degrees; and the mandibular plane-sella nasion (MP/SN) angle, from 52 to 17 degrees. The mandible rotated backward and caudally after the surgery.It is predictable that there will be a bony impingement between the coronoid process and the subcondyle of the proximal segment before surgery, and so an oblique osteotomy and coronoidectomy are planned ahead through an external approach.

Bunionette Repair With Midshaft Oblique Osteotomy and Distal Soft Tissue Repair

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Subcapital Oblique Osteotomy for Correction of Bunionette Deformity

The subcapital oblique osteotomy, or Weil osteotomy, is commonly used for other lesser toe deformities but has been infrequently described as a technique for correcting the bunionette deformity due to a large metatarsal head or mild increase in 4-5 intermetatarsal angle. Combined with distal soft tissue realignment, this technique is effective and has the advantage of allowing for elevation of the metatarsal head when increased plantar pressure presents as part of the pathology.

Combination joint-preserving surgery for forefoot deformity in patients with rheumatoid arthritis

Proximal osteotomies for forefoot deformity in patients with rheumatoid arthritis have hitherto not been described. We evaluated combination joint-preserving surgery involving three different proximal osteotomies for such deformities. A total of 30 patients (39 feet) with a mean age of 55.6 years (45 to 67) underwent combined first tarsometatarsal fusion and distal realignment, shortening oblique osteotomies of the bases of the second to fourth metatarsals and a fifth-ray osteotomy. The mean follow-up was 36 months (24 to 68). The mean foot function index scores for pain, disability and activity subscales were 18, 23, and 16 respectively. The mean Japanese Society for Surgery of the Foot score improved significantly from 52.2 (41 to 68) to 89.6 (78 to 97). Post-operatively, 14 patients had forefoot stiffness, but had no disability. Most patients reported highly satisfactory walking ability. Residual deformity and callosities were absent. The mean hallux valgus and intermetatarsal angles decreased from 47.0 degrees (20 degrees to 67 degrees) to 9.0 degrees (2 degrees to 23 degrees) and from 14.1 degrees (9 degrees to 20 degrees) to 4.6 degrees (1 degree to 10 degrees), respectively. Four patients had further surgery including removal of hardware in three and a fifth-ray osteotomy in one. With good peri-operative medical management of rheumatoid arthritis, surgical repositioning of the metatarsophalangeal joint by metatarsal shortening and consequent relaxing of surrounding soft tissues can be successful. In early to intermediate stages of the disease, it can be performed in preference to joint-sacrificing procedures.

Open wedge valgus tibial osteotomies: affecting the distinct ACL bundles

Valgus alignment affects the biomechanical behavior of the ACL, resulting in an increase of the in situ forces in the posterolateral (PL) bundle of the graft. The amount of valgus alignment creating such effects on the force remains unclear. Furthermore, the mechanistic rational for the increase in situ forces on the PL bundle when compared with the AM during the valgus osteotomy remained unclear. We hypothesized that increasing valgisation of the knee results in significantly increased obliquity and a resulting increasing elongation pattern and apparent strain of the PL bundle compared to the AM bundle. Six cadaver legs were used utilizing two commercial navigation systems including navigated high tibial osteotomy (HTO) and ACL measurements simultaneously. ACL footprints were registered for the central and identified AM and PL bundle. A stepwise oblique open wedge osteotomy was performed for 7.5° and 15° valgisation. Length changes and coronal plane obliquity were determined at 0° and 30° flexion. The apparent strain for each fiber was calculated. Valgisation significantly affects the length and obliquity of the PL portion of ACL. Valgisation of 7.5° appears to be a threshold for affecting PL length and obliquity without significant changes compared to 15°. The mean apparent strain for the PL bundle increases up to 14% with a 15° osteotomy in full extension, compared to 4% for the central and 2% for the AM bundle. HTO should be done prior to fixation the ACL graft in combined procedures as valgisation does affect graft length. Relative alignment influence on obliquity and length of the PL bundle should be considered in valgus knees.

Total hip arthroplasty for Crowe type IV developmental dysplasia of the hip.

Objective To develop the techniques in total hip arthroplasty (THA) for Crowe type Ⅳ developmental dysplasia of the hip (DDH) and assess the clinical results. Methods From October 1997 to Janurary 2009, 15 patients (20 hips) with Crowe type Ⅳ DDH underwent THA, including 5 patients with bi-lateral hip involved, 10 patients with unilateral. 18 hips were treated with Secur-Fit prosthesis while 2 hips were treated with Corail prosthesis. 6 hips underwent oblique subtrochanteric shortening osteotomy. 5 ac-etabulums were reaming through and were grafted with femoral head. Postoperative clinical and radiological results were evaluated. Results 2 patients lost of follow-up. 12 patients (16 hips) were followed up for the average 44.2 (5-92) months. There were 1 patient with bilateral THA died from hemorrhagic shock and MOF 1 week after operation, 1 patient with fat embolism survived, 2 cases with dislocation, 2 cases with femoral fracture. Among the 6 cases with osteotomy, 1 lost of follow up, 2 could walk freely with the visible fracture lines at 18 and 23 months postoperatively, 3 got union. Among the 5 cases with acetabular graft with femoral head, 1 lost of follow up, 4 were observed with union. The main Harris score was promoted from 24.7±5.7 preoperatively to 85.6±5.6 postoperatively (t=27.3, P=0.000). Conclusion For the complex DDH, this paper presents the trick to expose the true acetabulum, deepen acetabulum, femoral shortening, oblique osteotomy,using of the Scour-Fit prosthesis. THA associated with these techniques can effectively improve the outcomes of Crowe type Ⅳ DDH. Key words: Arthroplasty; replacement; hip; Hip dislocation; congenital; Osteoarthritis; hip; Osteotomy

Tibial Lengthening Over an Intramedullary Nail

Tibial Lengthening Over an Intramedullary Nail

Rib osteotomy and fixation: Enabling technique for better minithoracotomy exposure in cardiac and thoracic procedures

Chronic postthoracotomy pain is a common complication of thoracotomy, occurring in approximately 50% of patients.1Rogers M. Duffy J.P. Surgical aspects of chronic post-thoracotomy pain.Eur J Cardiothorac Surg. 2000; 18: 711-716Crossref PubMed Scopus (199) Google Scholar Severe and disabling pain affects 5% of patients after thoracotomy. Chronic postthoracotomy pain persists for greater than 2 months after the surgical procedure and is characterized by allodynic responses to mechanical and cold stimulation. To date, there is no objective evidence that postthoracotomy pain diminishes over time, despite popular opinion.2Buvanendran A. Kroin J.S. Kerns J.M. Nagalla S.N. Tuman K.J. Characterization of a new animal model for evaluation of persistent postthoracotomy pain.Anesth Analg. 2004; 99: 1453-1460Crossref PubMed Scopus (86) Google Scholar Chronic postthoracotomy pain is thought to result from intercostal nerve damage sustained during rib retraction or reduction.2Buvanendran A. Kroin J.S. Kerns J.M. Nagalla S.N. Tuman K.J. Characterization of a new animal model for evaluation of persistent postthoracotomy pain.Anesth Analg. 2004; 99: 1453-1460Crossref PubMed Scopus (86) Google Scholar A variety of surgical modifications have been developed to overcome this painful complication, ranging from local rib resection to muscle-sparing thoracotomies and mobilization of the intercostal nerve. Here we describe a thoracotomy technique that minimizes intraoperative trauma to the intercostal neurovascular bundle, preserves chest wall integrity, and permits adequate exposure of the surgical field. The patient is draped and positioned for a standard thoracotomy. Before incision, the ribs and intercostal spaces are carefully marked. The surface of the rib superior to the desired level of the incision is identified and an incision through the epidermis is made along the inferior margin of this rib. Electrocautery is used to clean the entire anterior surface of the superior rib over a length of 6 to 10 cm. Access to the neurovascular bundle is then achieved by dissection through external and internal intercostal muscle. At the posterior extent of the thoracotomy, the neurovascular bundle is locally dissected off the rib over about 3 cm. If present at the thoracotomy site, the innermost intercostal muscle is dissected free from the rib. An oblique osteotomy is made using a ring cutter, care being taken to avoid the mobilized neurovascular bundle (Figure 1, A). A soft tissue retractor is then used to reduce the direct contact with the neurovascular bundle. The rib retractor is then placed within the confines of the soft tissue retractor, minimizing direct contact with the rib bone superiorly and inferiorly while keeping the neurovascular bundle out of the way (Figure 1, B). When the surgical procedure is complete and the chest needs to be closed, the rib fragments are reduced and apposed in anatomic alignment. A modified SternaLock straight titanium plate (Biomet Microfixation Inc, Jacksonville, Fla) is secured in place with screws on either side of the osteotomy (Figure 1, C). We used this plate with 10-mm self-tapping screws to secure the plate early in our experience. Over the past 18 months, we have changed to using modified mid-face plates (Biomet Microfixation), using a thin 4-holed plate that is fixed with 7-mm self-tapping screws. Pericostal sutures are often not required to realign the intercostal spaces. The muscles, superficial fascia, and skin are closed in the standard fashion. Figure 2 is an operative photograph of the rib with the oblique osteotomy and Figure 3 shows the rib aligned and plated at the end.Figure 3The rib is aligned and plated at the end.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The standard thoracotomy incision is made along the superior border of the rib to avoid trauma to the neurovascular bundle during the incision. This approach leaves the neurovascular bundle vulnerable to intraoperative trauma from compression and tension during rib retraction. The resulting nerve damage subsequently causes chronic postthoractomy pain. The procedure we describe herein enables the surgeon to place the neurovascular bundle out of harm's way during intraoperative rib retraction. In addition, the osteotomy of the rib provides better access and visualization through a small incision. This is true for both cardiac and thoracic surgical procedures. These factors reduce the intraoperative nerve trauma and the resultant chronic postthoracotomy pain. We have used this technique in anterolateral thoracotomies for cardiac procedures in over 140 patients and 10 thoracic procedures between January 2005 and April 2009. None of these patients has had long-standing postthoracotomy pain. There have been no instances of delayed wound healing. The most remarkable finding is that these patients are able to cough early in the postoperative period without the dramatic and severe pain seen in most standard thoracotomies. As a result, physical therapy and mobilization in the postoperative period are much easier.