Oblique Osteotomy Research Articles

Condylar reconstruction by oblique sliding vertical–ramus osteotomy

Introduction: The posterior border of the mandibular ramus can be used as a pedicled graft for reconstruction of the condyle. This article describes a technique that is better in certain situations than the use of other autogenous grafts or alloplastic materials. Patients and methods: Three adult patients, two with osteochondroma and one with hyperplasia were treated by condylectomy and simultaneous reconstruction with the pedicled posterior mandibular border. A meticulous oblique osteotomy and reinsertion of the lateral pterygoid muscle was performed. Results: In all three cases an immediate mouth opening with stable occlusion was achieved. The interincisal opening was more than 40 mm after 3 weeks, with a deviation no greater than 4 mm towards the affected side. All excursive movements were present in all directions, and correction of the facial asymmetry was achieved. There was no T.M.J. pain and all patients expressed satisfaction during the follow-up of 56 months (average). An adequate remodelling of the neocondyle without resorption as well as a stable occlusion was observed in every case. Conclusion: Reconstruction of the condyle by sliding vertical-oblique ramus osteotomy provides, in cases of condylar tumours, excellent functional and cosmetic results.

Trapezo-metacarpal arthroplasty by rotation transfer of the trapezo-metacarpal joint. Anatomical study and operative technique

To correct trapezium dysplasia we propose a new surgical technique. The operation consists of a double osteotomy of the trapezium and of the first metacarpal base, thereby harvesting the trapezo-metacarpal joint en-bloc. Vascularization is via the radial artery pedicle divided at the first web level. The articular block is then rotated 180 degrees on the longitudinal axis of the thumb. An anatomic study was performed on six fresh cadaveric upper limbs. The radial artery was injected with colored latex, 5 cm above the wrist. The peri-articular vascular network was studied. The feasibility of harvesting and rotating the articular bloc after double osteotomy of the first metacarpal basis and the trapezium was also studied. In all the cases, the radial artery was present with branches supplying the peri-articular vascular network. After double osteotomy of the metacarpal base and of the trapezium, the articular bloc was harvested and rotated by 180 degrees. We describe the surgical technique. The surgical technique has been confirmed with the first clinical cases. The double oblique osteotomy with rotation of the articular bloc corrects trapezium dysplasia and preserves first metacarpal abduction. This procedure appears to be a solution in cases of trapezium dysplasia associated with instability and early stage osteoarthritis.

Proximal oblique crescentic osteotomy in hallux valgus.

Twenty-six patients with moderate-to-severe hallux valgus deformities were evaluated before and after treatment. All of the patients had incongruent great toe joints. The patients underwent modified proximal crescentic osteotomy, which was termed proximal oblique crescentic osteotomy. The results were evaluated at an average follow-up time of 55 weeks. Objective criteria were hallux valgus angle, intermetatarsal angle, shortening of the first metatarsal, and angulation at the osteotomy site. Clinical evaluation was made according to the rating system of the American Orthopaedic Foot and Ankle Society. The mean correction of the hallux valgus and intermetatarsal angles was 22.1 degrees and 9.9 degrees, respectively. Short-term results indicate that proximal oblique crescentic osteotomy is effective in the treatment of hallux valgus; its advantages over other procedures include its technical ease and low rate of complications.

A biomechanical evaluation of lateral plating of distal radial shaft fractures

Purpose In this ex vivo biomechanical study we compared the maximum anterior/posterior bending moment, maximum torque, torsional stiffness, and twist angle at failure of distal radial shaft (Galeazzi) fractures stabilized with lateral plating (LP) and anterior plating (AP) and subjected to 4-point anterior/posterior bending and torsion. Methods Simulated fractures (oblique osteotomy between the middle and distal thirds of each radius) were created in 21 pairs of fresh, unembalmed, cadaver radii. One radius from each pair was stabilized with AP (n = 21); the contralateral radius was stabilized with LP (n = 21). Eleven pairs of specimens were tested to failure in torsion; the remaining 10 pairs were tested to failure in 4-point anterior/posterior bending. Differences between plating groups were checked for significance using paired t-tests. Results AP fixation was stronger in torsion (12.8 ± 5.6 N-m) and anterior/posterior bending (40.1 ± 25.7 N-m) than LP fixation (10.7 ± 5.6 N-m and 36.0 ± 30.5 N-m, respectively), although the differences were not significant. Similarly there was no significant difference in twist angle at failure (29° ± 13° vs 23° ± 10°) or in torsional stiffness (0.6 ± 0.2 N-m/° vs 0. 6 ± 0.2 N-m/°) between AP and LP fixations, respectively. Conclusions Because LP fixation was not mechanically superior to AP fixation and required additional tendon elevation and dissection of the dorsal sensory nerve and possibly of the lateral antebrachial cutaneous nerves, AP fixation appears to be the preferable treatment for Galeazzi fractures.

Lower extremity angular malunion: evaluation and surgical correction.

The lower extremity has a mechanical axis with joint orientation that allows joint longevity and efficiency in bipedal gait. When normal alignment is lost because of trauma or other conditions, deviations from this anatomic norm may be deleterious to long-term joint function. In fractures that have healed with angular malunion, all facets of the deformity must be carefully considered, including alteration in length, rotation, alignment, and translation. Once all elements are fully defined, the effects of the malunion on mechanical axis and joint orientation can be understood. Techniques for surgical correction include wedge, dome, and oblique osteotomies and distraction osteogenesis. Each method possesses characteristics appropriate for certain clinical situations. Judicious patient selection and thoughtful preoperative planning may allow restoration of normal mechanics.

The oblique proximal phalangeal osteotomy in the correction of hallux valgus

An oblique proximal phalangeal osteotomy is introduced as an alternative to the Akin procedure for the treatment of hallux valgus. It consists of a single oblique osteotomy directed from proximal-dorsal to plantar-distal. A retrospective review of 32 patients who underwent 36 oblique proximal osteotomies is presented. The mean follow-up was 11 months (range, 3 to 21 months). Pre- and postoperative radiographic measurements of the distal articular set angles showed an average correction angle of 12° (range, 7° to 22°; SD = 2.99). Mean range of first metatarsophalangeal joint motion was 82% of the preoperative value when combined with distal metatarsal osteotomy, and 87% of the preoperative value without a distal metatarsal osteotomy. Time to clinical and radiographic healing averaged 5 weeks (range, 4 to 8 weeks). The average amount of phalangeal shortening was 1 mm (range, 0 to 2 mm). There were no delayed or nonunions. Subjective assessment conducted by retrospective review of 19 patients at 6 months postoperatively showed that 17 were completely satisfied (90%), 1 was satisfied (5%), and 1 fairly satisfied (5%). Nineteen would have the surgery again (1 with reservations). Eighteen were very satisfied with appearance and 1 was improved. Fourteen returned to shoe gear at weeks 6 to 8, and 5 returned at weeks 8 to 12. Eighteen were satisfied with pain relief and 1 was improved. The study indicates that the oblique proximal phalangeal osteotomy is an effective, reliable, and technically simple procedure for correction of deformities of the proximal phalanx. The advantages include minimal shortening, ease of adjustability, and a construct conducive to rigid fixation.

Magnetic resonance imaging of the growth plate in late-onset tibia vara.

We used Magnetic resonance imaging (MRI) in five patients (six knees), mean age 13.2 (12-15) years, with late-onset tibia vara (Blount's disease), to study the growth plate and its abnormalities. The MRI study was classified for severity of disease and compared with a radiographic classification. In severely involved knees, MRI indicated severe growth-plate changes on both sides of the knee joint. Widening in the entire proximal tibial growth plate, involvement of the distal femoral growth plate, as well as cartilage invaginations into the metaphyses, were constant findings. Three knees were treated operatively with oblique tibial osteotomy and three with lateral hemiepiphysiodesis. Two severely involved patients treated initially with hemiepiphysiodesis required additional surgery. The three patients with mild disease treated with tibial osteotomy had good clinical and functional results. This study suggests that extensive growth-plate changes in severe, late-onset tibia vara preclude successful treatment by tibial hemiepiphysiodesis. In addition, oblique osteotomy, which was successful in mild cases, was problematic in severe cases.

Correction of lower extremityangular malunion

Fractures often heal with angular, rotational, or length malunion. In most situation, these deviations from the normare functionally well tolerated. Occasionally, malunions lead to problems of joint axis deviation, articular cartilage overload, instability, cosmesis. Although the existing literature is inconclusive about the long-term implications of angular malunions, there are situations where clinical judgment suggests that malunion correction is indicated. If surgical correction is contemplated, precise deformity assessment and preoperative planning is imperative. Available techniques include wedge osteotomy, oblique osteotomy, dome osteotomy, and distraction osteogenesis. Each of these methods possesses characteristics appropriate for certain clinical situations. The indications and surgical techniques of these methods will be discussed. In the author's experience, judicious patient selection, combined with thoughtful preoperative planning, may restore normal mechanics to legs malaligned from trauma.

Long oblique distal osteotomy of the fifth metatarsal for correction of tailor's bunion: a retrospective review.

A long-term retrospective review of a long oblique distal osteotomy of the fifth metatarsal for correction of a tailor's bunion deformity is presented. The technique, results, and follow-up of this procedure are described. The long oblique distal osteotomy was performed on 25 feet on 16 patients. Follow-up ranged from 11 to 110 months with an average of 64.4 months. The average preoperative intermetatarsal 4-5 angle and lateral deviation angle improved from 10.88 degrees and 4.24 degrees, respectively, to 5.52 degrees and -4.24 degrees postoperatively, respectively. A modified scoring scale for lesser metatarsal procedures was used, showing an average postoperative score of 94 out of 100 possible points. Subjectively, 96% (24 of 25) of feet that underwent surgery were rated as excellent or good. Complications included one patient with paresthesias, one soft-tissue infection, and 2 patients had irritation from screws. The authors conclude that the long oblique distal osteotomy is a viable alternative in the correction of tailor's bunion deformity.

Oblique osteotomy for multiplanar correction of malunions of the femoral shaft.

Between 1990 and 1996, six patients had oblique femoral osteotomies for symptomatic posttraumatic femoral malunions. In each patient, an oblique osteotomy was done that allowed for correction in the coronal, transverse, and sagittal planes. Fixation was achieved with lag screws supplemented by a neutralization plate. The average followup was 49 months (range, 18-99 months). All osteotomies healed at an average of 2.9 months (range, 2.5-4.0 months). Postoperatively, all patients had full range of motion in the ipsilateral hip and knee and could bear full weight without pain. Radiographically, the average deformity measured on anteroposterior radiographs improved from 21.6 degrees to 4.2 degrees varus. The average deformity on lateral radiographs improved from 22.5 degrees to 7.0 degrees antecurvatum. In all patients, the leg lengths were within 0.5 cm of each other and axial alignment was within 10 degrees of the contralateral limb. The use of an oblique osteotomy is a simple and predictable method of correcting complex posttraumatic femoral malunions and provides excellent surgical and clinical results.

Ulna shortening osteotomy using a compression device

Purpose: To report the functional and radiographic outcomes of a cohort of patients treated for ulnar impaction syndrome with a single technique of ulnar shortening osteotomy. Method: We performed ulnar shortening osteotomy on 18 consecutive patients over a 10-year period by using an oblique osteotomy and compression plating technique with an AO compression device (Synthes, Paoli, PA). There were 11 men and 7 women in the series, with an average age of 32.7 years. All patients were graded before and after surgery with the modified wrist grading system of Chun and Palmer. Results: All 18 osteotomies healed over an average of 6–8 weeks. There were significant improvements in pain, function, strength, and range of motion at an average follow-up of 3 years. Thirteen wrists were graded excellent, 3 good, and 2 fair. There were no postoperative complications, however, 8 patients ultimately required plate removal for local discomfort. Conclusions: This study showed that ulnar shortening osteotomy using an oblique osteotomy and an AO compression device is easy to execute and is associated with satisfactory outcomes. Healing time is rapid and postoperative cast immobilization is not required. (J Hand Surg 2003;28A:88-93. Copyright © 2003 by the American Society for Surgery of the Hand.)

Self-reinforced bioabsorbable versus metallic fixation systems for metacarpal and phalangeal fractures: a biomechanical study.

Bioabsorbable fixation devices offer a useful option to treat small bone fractures of the hand if the prerequisite of reliable and stable osteofixation is met. We compared the stabilities of various bioabsorbable fixation devices with metallic fixation devices by using an oblique osteotomy model in radial to ulnar orientation. The 1.5-mm, self-reinforced, poly-L-lactide (SR-PLLA) pins provided fixation rigidity comparable with 1.5-mm K-wires in dorsal and palmar apex bending, whereas in lateral apex bending and in torsion the rigidity was equal to that of 1.25-mm K-wires. The 2.0-mm, self-reinforced, poly-L/DL-lactide (SR-P(L/DL)LA) 70/30 screws provided rigidity comparable with that of 1.5-mm K-wires in all testing modes. The bioabsorbable plate considerably enhanced the bending stabilities of the fixation system, but a single interfragmentary screw provided only limited rotational rigidity. The results show that by using ultra-high strength self-reinforced implants adequate fixation stability for hand fracture fixation can be achieved.

Ulnar Shortening Osteotomy

Ulnar shortening to unload the ulnocarpal ligamentous complex. Clinically relevant ulnar impaction syndrome, be it congenital or posttraumatic. Concomitant pronounced malunion of the radius. Osteoarthritis of the distal radioulnar joint. Ulnopalmar approach. Oblique osteotomy of the ulna in its distal third. Removal of a bony wafer of predetermined thickness. Internal fixation with a 7-hole LD-DC plate or special plate and lag screw. 29 patients (14 men, 15 women, average age 42 years) underwent an ulnar shortening osteotomy for a therapyresistant ulnar impaction syndrome. Follow-up after an average of 25(7–37) months. Average amount of shortening 4.5 (1.5–13) mm. 72% reduction of pain as determined with a visual analog scale. The range of motion was improved by 7% in extension/flexion, by 8% in abduction/adduction, and by 11% in pronation/supination. Grip strength measured with a vigorimeter (balloon size 5) increased by 12%. Complications: three malunions, effectively treated by revision of internal fixation.

The Weil osteotomy for treatment of dislocated lesser metatarsophalangeal joints: good outcome in 21 patients with 42 osteotomies.

Hardly any surgical methods are available for metatarsalgia caused by a dislocated lesser metatarsophalangeal joint (MTP) that do not sacrifice the joint. We reviewed retrospectively the outcome of 60 metatarsal Weil osteotomies for correction of dislocated lesser MTP joints in 31 patients. Between 1995 and 1996, 31 consecutive patients were treated with a Weil osteotomy at 2 institutions. The Weil osteotomy is an oblique osteotomy of the metatarsal neck and shaft, parallel to the ground surface, that controls shortening of the metatarsal by internal fixation with screws or pins. At an average final follow-up of 30 (24-44) months, all patients were interviewed, using a standardized questionnaire based on the AOFAS Lesser Metatarsophalangeal-Interphalangeal Scale. Recurrent or transfer metatarsalgia, formation of callus, mobility and dislocation of the MTP were noted on physical examination. Dorsoplantar and lateral weightbearing radiographs taken preoperatively and at the time of final follow-up were examined for alignment of the metatarsal heads, subluxation or dislocation and for evidence of nonunion, or malunion of the metatarsal osteotomy. We had excellent results in 21 patients (42 osteotomies). A major complication was plantar penetrating hardware in 10 cases (3 screws and 7 pins). We conclude that the Weil osteotomy is a good method for correcting metatarsalgia caused by dislocation of the MTP joint.

Fracture of the proximal tibia six months after Fulkerson osteotomy

The Fulkerson osteotomy has proved to be a reliable treatment for subluxation of the patella due to malalignment. Aggressive rehabilitation in the early postoperative period is unwise since the proximal tibia is weakened by the oblique osteotomy. Early weight-bearing and unrestricted activity have caused fractures in a few patients. Even late in the postoperative period the osteotomy may adversely influence the biomechanical properties of the proximal tibia. We describe two athletes who sustained a fracture of the proximal tibia, during recreational activities, six months after a Fulkerson osteotomy. Both had been bearing full weight for about ten weeks without complaint. Bony healing of the osteotomy had been demonstrated on plain radiographs at ten and at 12 weeks. After a Fulkerson osteotomy, jogging and activities which impose considerable impact force should be discouraged for at least nine to 12 months.

Diagnosing deltoid injury in ankle fractures: the gravity stress view.

In the lateral malleolar ankle fracture without talar shift there is much uncertainty regarding the diagnosis of deltoid ligament injury severe enough to require surgical treatment. The current study evaluated the mechanical integrity of the ankle using a novel gravity-stress mortise radiographic view, which is practical for clinical use. Eight cadaveric lower extremities were tested under the following conditions: (1) intact ankle, (2) distal fibular oblique osteotomy, (3) plated fibula after osteotomy, (4) transection of the superficial deltoid with fibula osteotomized or plated, and (5) all possible combinations of deep deltoid transection with superficial deltoid transected or repaired and fibula osteotomized or plated. For each condition, a mortise radiograph was taken of the specimen while it was mounted horizontally, lateral side down. Fibular osteotomy with or without transection of the superficial deltoid did not alter the mortise radiograph appearance of the ankles. With combined deep and superficial deltoid transection and fibular osteotomy, the talus always (eight of eight specimens) showed a lateral shift of 2 mm or greater and a valgus tilt of 15 degrees or more. The gravity stress view of the ankle was found to reproducibly document destabilizing deltoid ligament damage.

Flexible hinge toe implant arthroplasty for rheumatoid arthritis of the first metatarsophalangeal joint: long-term results

We report the long-term clinical results and survival rate of the implant in flexible hinge toe implant arthroplasty of the first metatarsophalangeal joint, combined with a shortening oblique osteotomy of the metatarsal neck in the lateral toes, in patients with rheumatoid arthritis. Between 1983 and 1990, arthroplasty was performed on 97 feet in 66 patients. Twenty-seven patients died; follow-up information was available for 60 feet in the remaining 39 patients, who were followed for an average of 12 years. Twenty-nine patients (74%) were satisfied with the outcome after surgery, 7 were satisfied but had some pain or recurrent deformities, and 3 were unsatisfied. Radiologically, visible fracture was identified in nine implants. Four implants were removed because of infection (n=2) or recurrent deformity (n=2); no implant was removed because silicone synovitis developed. With revision as the endpoint, the implant survival rate was 93% at 10 years, and with radiographic implant fracture as the endpoint, the implant survival rate was 87% at 10 years. Shortening oblique osteotomy of the lateral toes appeared to decrease the rate of implant fracture and should be performed concomitantly with implantation when rheumatoid forefoot deformities are being reconstructed.

Ulnar shortening after failed arthroscopic treatment of triangular fibrocartilage complex tears.

Ulnar shortening osteotomy was performed in 11 wrists with ulnar abutment syndrome, after failed arthroscopic surgery on the TFCC (ten debridements, one repair). A delayed union was present in three, a non-union occurred in two, of whom one needed a revision and grafting procedure. According to the Mayo wrist score, only four had an acceptable outcome. Patient's satisfaction was higher: seven were satisfied, four were not. The postoperative wrist pain score was good in ten patients. Overall outcome was not very successful. Problems related to the procedure could be avoided by adapting the technique (oblique osteotomy, palmar placement of the plate, and compression devices). The key statement remains however to us; ulnar sided wrist pain thought to be caused by an ulnar abutment is not necessarily resolved by decompressing the ulnocarpal joint.

Development of a device for the delivery of agents to bone during distraction osteogenesis.

Various agents have been theoretically and experimentally implicated as mediators of distraction osteogenesis (DO). The purpose of this study was to develop a vehicle for the potential delivery of these factors to the region of the distraction site in an attempt to manipulate this biologic process. Three adult mongrel dogs (12 months old) had oblique osteotomies performed bilaterally through the gonial regions. In group I, the external distracter was affixed to the right hemimandible of two dogs (n = 2 hemimandibles) with cannulated pins (external diameter = 1.5 mm; lumen diameter = 1.0 mm; length = 60 mm), whereas the distracter on the left was affixed with standard, noncannulated pins of the same dimensions. In group II, cannulated pins were used to affix the external distracter to both hemimandibles (n = 2 hemimandibles) of a dog. The devices were activated after a 5-day latency period and were lengthened at a rate of 1 mm/day for 20 days. During the distraction period, 0.1 ml/d of sterile india ink was injected into the cannulated pins, after which the sterile stylet was replaced. The activation protocol was followed by 28 days of fixation (consolidation period). The hemimandibles from group I underwent removal of soft tissues, acetone fixation, and gross examination/photography, whereas the hemimandibles from group II were prepared for histologic evaluation (whole mount, hematoxylin and eosin staining). All dogs survived to the end of the study and demonstrated successful DO without evidence of complications. Hemimandibles in group I displayed evidence of india ink on both the lingual and buccal cortex around the cannulated pin site, in the regenerate and on the neocortices of the distracted segment. Hemimandibles of group II showed histologic evidence of the india ink being deposited densely around the cannulated pin site and extending in a radial fashion around the pin site into the regenerate. This study demonstrates for the first time a vehicle device for the delivery of an inert dye to the regenerate site during distraction osteogenesis. This vehicle offers the potential of delivery of various factors implicated in distraction osteogenesis (i.e., mitogens) in an attempt to alter this process and also substances (i.e., chemotherapy, antibiotics, etc.) for use in the treatment of various osteopathies.

Mechanical analysis of the healing of different osteotomies fixed externally.

Under standard conditions the left tibia was osteotomised in nine sheep. The osteotomy was transverse in six, and oblique in three. The osteotomies were fixated using a strain-gauge-monitored unilateral external fixator. The fixation was rigid in three sheep with a transverse osteotomy (group 1) and also in three sheep with an oblique osteotomy (group 2). The fixation was dynamic in three sheep with a transverse osteotomy (group 3) using a roller-bearing mechanism allowing 1 mm of axial displacement. The bone callus stiffness increased progressively with time. One month after osteotomy the load force through the fixator in groups 1 and 2 was more than 20%, whereas the equivalent load force in group 3 was only about 5%.