Tibial and Femoral Osteotomy

S. Robert Rozbruch, MD

Austin T. Fragomen, MD

Dr. Fragomen or an immediate family member has received royalties from Stryker; is a member of a speakers’ bureau or has made paid presentations on behalf of Nuvasive and Smith & Nephew; serves as a paid consultant to Nuvasive, Smith & Nephew, and Synthes; and serves as a board member, owner, officer, or committee member of the Limb Lengthening Research Society. Dr. Rozbruch or an immediate family member has received royalties from Small Bone Innovations and Smith & Nephew; is a member of a speakers’ bureau or has made paid presentations on behalf of Ellipse Technologies, Smith & Nephew, and Stryker; serves as a paid consultant to Ellipse Technologies, Small Bone Innovations, Smith & Nephew, and Stryker; has received nonincome support (such as equipment or services), commercially derived honoraria, or other non-research–related funding (such as paid travel) from Informa and Springer; and serves as a board member, owner, officer, or committee member of the Limb Lengthening Reconstruction Society.

Introduction

Osteotomy is a reconstructive surgery that involves cutting the bone to attain limb deformity correction and/or limb length equalization. In this chapter, we focus on the long bones of the lower extremity: the femur and tibia. Osteotomy of the femur and tibia may be indicated for both children and adults. In most cases, the goal of rehabilitation is simply to maintain adjacent joint range of motion (ROM) and muscle strengthening as well as progressing gait within certain weight-bearing limitations. There are a variety of treatment variations that include location of osteotomy, acute or gradual deformity correction, bone lengthening, and choice of hardware. The etiologies of deformity include congenital, posttraumatic, and developmental. The etiology, location of the osteotomy, use of internal or external fixation, postoperative immobilization, and the amount of limb lengthening or shortening will affect the rehabilitation needs and challenges (Table 45.1).

Surgical Procedure

Osteotomy is indicated for correction of deformity and/or limb lengthening. When analyzing a deformity, the proximal and distal bone axes are drawn to form an angle at the apex of deformity. In most cases, the osteotomy is performed at the apex of deformity; the bone is straightened and then stabilized. Deformity correction may be done acutely with an open, closed, or neutral wedge, and stabilized with plate and screws, an intramedullary (IM) rod, or an external fixator. The indications for gradual correction are large deformity, compromised soft-tissue envelope, and the need for bone lengthening. These are done with external fixation or an internal lengthening IM rod.

Distraction osteogenesis is used for gradual bone lengthening and deformity correction. Ilizarov showed that bone could successfully regenerate if a low-energy osteotomy was performed, proper stability was accomplished, and distraction was done with a proper rate and rhythm (usually 1 mm per day divided into 3–4 adjustments per day).

Osteotomy Technique Variations

Acute Deformity Correction and Insertion of Plate

This technique is indicated for moderate deformity in the proximal or distal femur. A common use of this technique is for correction of a distal femur valgus deformity with an open wedge correction and insertion of a locked plate. Other indications include varus deformity of the distal femur and proximal femur malunion. In the tibia, acute correction is used to correct moderate varus deformity of the proximal tibia with an open wedge correction and insertion of a locked plate. Other indications include angular deformity correction of the distal tibia and realignment of the ankle.

Acute Deformity Correction and Insertion of Intramedullary Rod

This approach is indicated for correction of rotational and/or angular deformity in the diaphysis of the femur. This is indicated for a patient with congenital femur malrotation or for a malunion after trauma. While this can be done in the tibia, it carries a greater risk of compartment syndrome and nerve injury.

Limb Lengthening with Internal Lengthening Intramedullary Rod

This approach is indicated for leg length discrepancy (LLD) and can be done in the femur or tibia. Acute correction of moderate deformity may be done followed by gradual lengthening. In the femur, the IM rod can be inserted antegrade or retrograde.

Table 45.1 OSTEOTOMY TYPES WITH SURGICAL AND REHABILITATION NOTES

Location	Fixation	Acute/Gradual Correction	Diagnosis/ Etiology	Goal of Surgery	Surgical Notes	Rehabilitation Guidelines
Proximal femur	Plate	Acute	Malunion	Rotational and angular deformity correction	Use blade plate	PWB for 6 wk; hip ROM
Femur diaphysis	IM rod	Acute	Malunion, congenital	Rotational and angular deformity correction	Percutaneous osteotomy and rod insertion	WBAT; hip and knee ROM
Distal femur (DFO)	Plate	Acute	Arthrosis, knee deformity	Angular deformity correction	Use locked plate	PWB for 6 wk; knee ROM
Middle to distal femur	Internal lengthening rod	Gradual	LLD, deformity Malunion, congenital	Equalization of leg lengths and correction of deformity	Can do acute correction of angular and rotational deformity	PWB for 3–4 mo, hip extension, knee ROM
Middle to distal femur	External fixation	Gradual	LLD, large deformity Malunion, congenital	Equalization of leg lengths and correction of deformity	Can do acute correction of angular and rotational deformity	WBAT; hip extension, knee ROM
Proximal tibia (PTO)	Plate	Acute	Arthrosis, knee deformity	Correction of deformity	Correct varus deformity <10°	PWB for 6 wk; knee ROM
Proximal and middle tibia	External fixation	Gradual	Tibial deformity and LLD, arthrosis, knee deformity	Equalization of leg lengths and correction of deformity	Used for complex or large deformity	WBAT, knee and ankle ROM, especially knee extension, ankle DF
Middle tibia	Internal lengthening rod	Gradual	LLD	Equalization of leg lengths		PWB for 3–4 mo, knee and ankle ROM, especially knee extension, ankle DF
Distal tibia (SMO)	Plate	Acute	Ankle deformity Malunion, congenital	Correction of deformity	Correct varus or valgus of <10°	PWB for 6 weeks, ankle ROM
Distal tibia	External fixation	Gradual	Ankle deformity Malunion, congenital LLD	Equalization of leg lengths and correction of deformity	Used for complex or large deformity	WBAT, ankle ROM, especially DF
DF = dorsiflexion of ankle, DFO = distal femoral osteotomy, IM = intramedullary, LLD = leg length discrepancy, PTO = proximal tibial osteotomy, PWB = partial weight bearing, ROM = range of motion (active and passive), SMO = supramalleolar osteotomy, WBAT = weight bearing as tolerated.

Lengthening and/or Gradual Deformity Correction with External Fixation

This approach is indicated in children with open growth plates and for patients who have narrow IM canals or deformity, for whom an IM rod is contraindicated. This is also indicated for patients with large deformity for whom acute correction would be dangerous. Patients with infection, or poor soft-tissue envelope, are indicated for external fixation. The external fixator also allows fine-tuning of deformity correction after surgery is complete. This can be helpful in complex situations in which the goal is to achieve a plantigrade foot. Patient feedback regarding the position of the foot while the patient is standing can be very reliable.

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