The base of the elevated bone is protected using cotton for cast padding or an Esmarch bandage, which is wrapped around the soft tissue to prevent damage to normal tissue when freezing. Two to three clean surgical sheets are passed through the pedicle, and the hole through which they are placed is closed using tape. The pedicle is tilted during curettage to enable the curetted tumor not to fall onto a sheet as much as possible. Carefully, curettage is performed and bone tunnels are created. This procedure is important to prevent fracture of the affected bone as blood and tumor tissue expand with freezing. Before the freezing process, a Kirschner wire can be used to place a few small holes into the bone that is to be treated. When the top surgical sheet that is passed through the pedicle is removed after curettage, the affected limb needs to be supported firmly so that the elevated bone does not contact the surrounding sheet. The basic materials needed for nitrogen treatment are a sterilized vacuum flask (Dewar flask) and liquid nitrogen. About 15–20 L of liquid nitrogen should be available, a volume sufficient to immerse the affected bone. The boiling point of liquid nitrogen is very low at −196 °C, and, thus, there is no concern about temperature control during the treatment. In the freezing procedure, it must be confirmed that the bone is immersed in liquid nitrogen up to the marked area while treating it in liquid nitrogen for 20 min. During this process, one should confirm that normal tissue does not freeze such as by placing one’s fingers between the affected limb and the rim of the Dewar flask. After freezing, the treated bone is slowly removed from the Dewar flask by raising the operating table. The surgical sheet that has been passed through the pedicle is removed carefully. The bone is thawed at room temperature for 15 min and then thawed in 30 °C distilled water for about 15 min. If the bone defect caused by curettage of the tumor is large, it should be filled using autologous bone, artificial bone, or bone cement to maintain the strength of the treated bone.

Rigid fixation of the treated bone is achieved using double plate fixation or intramedullary nail-plate fixation while taking care not to cause rotation or create a gap in the osteotomy site. In the osteotomy site, bone union is promoted in the junction between the treated bone and host bone and in some cases by bone grafting at the junction. In pedicle freezing method, good bone union is achieved. The soft tissue is thought to be important in the stability of the joint and functional recovery of the affected limb. After fixation of the treated bone, the soft tissue is sutured to the attachment site that has been left as much as possible on the treated bone or it is reattached to the treated bone using screws with washers. A drain must always be placed. Subcutaneous suture is carefully performed and the wound is closed.

In the pedicle freezing method, the affected bone can be treated with liquid nitrogen by dislocation of the joint without osteotomy in some cases. In such cases, it is not necessary to wait for bone union, and weight-bearing walk can begin a few days after surgery. If both pedicle freezing method and free freezing method are indicated for a patient, we prefer the pedicle freezing method.