30: Sofield Osteotomy with Intramedullary Rod Fixation of the Long Bones of the Femur/Tibia

Sofield Osteotomy with Intramedullary Rod Fixation of the Long Bones of the Femur/Tibia

Samantha A. Spencer

Indications

Severe long-bone deformity such as in osteogenesis imperfecta (OI) or rickets

Long-bone fracture with deformity

Recurrent fracture

Pitfalls

• Be certain the bone is large enough for the rod chosen.

• Counsel the patient and family regarding the risks of this surgery: complication rates are 55% in OI, regardless of rod type; 51% rate of re-rodding for simple rods and 27% rate of re-rodding for telescoping rods.

• For severe OI patients, be sure the cervical spine has been imaged appropriately and that an experienced anesthesia team is available; fiberoptic intubation is often needed.

Controversies

• Sofield osteotomy and rodding for deformity alone may not improve function.

Examination/Imaging

Anteroposterior (AP) and lateral radiographs of the entire bone are obtained (Fig. 1).

FIGURE 1

Treatment Options

• Bracing for deformity

• Cast immobilization for fracture

• Observation

Surgical Anatomy

In the relevant long bone, neurovascular injury may be avoided by making the incision over the apex of the deformity, spreading longitudinally through muscle, and then doing careful subperiosteal dissection around the bone at the osteotomy site.

Positioning

The patient is placed supine on a radiolucent table.

Intraoperative fluorscopy is utilized.

The entire gluteal area must be draped free to access the greater trochanter for rodding; the entire lower extremity is prepped out.

For surgery on one lower extremity, a trochanter roll is appropriate (Fig. 2), with the ipsilateral arm across the chest.

FIGURE 2

For surgery on bilateral lower extremities, access to both gluteal areas is ensured using a stack of blankets to elevate the patient if needed (Fig. 3).

FIGURE 3

Pearls

• A stack of blankets for a small patient allows good access to the legs and works for bilateral procedures. This will allow access to the greater trochanters and will allow enough knee flexion for concomitant tibial rodding if needed.

Pitfalls

• To place an intramedullary device down the femur, the patient needs to be at the side of the table or elevated enough to allow room to access the entry point to the femoral canal.

Portals/Exposures

Step 1 (Approach A)

The entry point to the greater trochanter is identified. Figure 4 shows the trochanteric entry point for a femoral rodding with a Schnidt forceps marking the first osteotomy.

FIGURE 4

The incision needs to be posterior and inferior to the tip of the greater trochanter. A 2-cm incision is sufficient.

Dissection is performed bluntly and longitudinally, spreading through the gluteus maximus until the tip of the greater trochanter can be accessed.

Pearls

• A spinal needle can be used to be certain of the site with fluoroscopy before making the incision.

Pitfalls

• If the incision is too distal, it will not be possible to properly access the femoral canal without cutting through the lateral trochanter.

Procedure

Step 1 (Approach B)

The fracture site is accessed first, and a guidewire is passed retrograde through the greater trochanter (Fig. 5). The guidewire is drilled into the greater trochanter and down the canal, and AP and lateral radiographs are checked for position.

FIGURE 5

Drilling stops when the wire is at a cortex; this will be the apex of the deformity and the appropriate position for the first osteotomy.

Only gold members can continue reading. Log In or Register to continue

Related

Stay updated, free articles. Join our Telegram channel

Tags: Operative Techniques Pediatric Orthopaedic Surgery

Jun 7, 2016 | Posted by admin in ORTHOPEDIC | Comments Off

Full access? Get Clinical Tree

Get Clinical Tree app for offline access

Get Clinical Tree app for offline access