OSTEOTOMY

From Big Medical Encyclopedia

OSTEOTOMY (grech, osteon a bone + tome a section, a section) — orthopedic operation of a section of a bone.

For the first time O. was executed at an anchylosis of a hip joint instead of osteoclases (see) the Philadelphian surgeon J. R. Barton in 1826

Indications and Contraindications

the Indication for O. are various inborn and acquired deformations of bones, preferential long tubular, false and bone ankyloses in joints in functionally unprofitable (vicious) situation, and also congenital dislocation of a hip and its effect, other dysplastic and degenerative and dystrophic diseases of a skeleton.

Contraindications to O. all-surgical, including purulent diseases of any localization.

Training of patients

Training of patients for O. of features has no. Operation is made with use of any of the types of anesthesia applied in surgery; at O. of large bones the anesthesia is preferable.

A technique

O. carry out by means of a chisel or an oseotome, a chain or usual saw (see. Orthopedic tools ). In recent years, especially at children, quite often for O. use ultrasonic cutting of bones (see. Ultrasonic therapy ). After O. bones in new situation fix by means of nails, plates, bone transplants, devices for a chreskostny extra focal osteosynthesis, and also applying plaster bandages, sometimes skeletal traction (see. Extension , Plaster equipment , Distraktsionno-kompressionnye devices , Osteosynthesis ).

The lake can be closed and opened. At the closed O. make a skin section 2 — 3 cm long then the oseotome is carried out to a bone and cross it on 3/4 diameters; the remained site of a bone is cracked. This operation is usually less traumatic, than open O., but is accompanied by risk of wound of large vessels and nervous trunks.

At the open O. used much more often the section of skin is made within 10 — 12 cm and bare a bone. In a zone O. the periosteum is economically separated the raspatory. Under a bone place elevators and under control of an eye an oseotome make O. Neredko through both bast layers of a bone carry out to future O.'s planes by a thin drill of an opening and through them cut a bone. This reception gives the chance to carry out O. precisely in the planned plane.

In a form of a section of a bone apply linear (cross or slanting) and figured O. (angular, step, fenestrated, zhelobkovy). At excision of a wedge from a bone speak about wedge-shaped O. Segmentarna O. call a section of a bone at several levels.

On the purpose of operation O. conditionally divide all on corrective and O. for creation of a support. O. for correction of angular deformation of a bone can be an example of operations of the first group at its incorrectly accrete change, O. for lengthening of a bone. The lake for creation of a support is intertrochanteric O. of a hip according to Mac-Marri, O. of a basin at congenital dislocation of a hip. However most often at O. solve both problems — correct deformation of a bone or its vicious situation and create a support (e.g., O. at an anchylosis in vicious situation). At last, O. can be independent operation or only a stage of other operation. E.g., O. of a big spit at various operations on a hip joint.

Fig. 1. Roentgenograms (above) and schemes to them (in the bottom of) the left hip joint at the shift of a hip up and its reduction: and — to an osteotomy (1 — a free joint hollow, 2 — the head of a femur, on the scheme is shown by a dotted line the line of an osteotomy); — after an osteotomy (on the scheme shooters specified the head of a femur reduced in a joint hollow; the hip is taken away).
Fig. 2. The diagrammatic representation of options of an osteotomy of a femur in subtrochanterian area at an anchylosis in a hip joint: 1 — cross, 2 — slanting, 3 — angular, 4 — hinged, 5 — with an intramedullary osteosynthesis, 6 — fenestrated, 7 — laminar, 8 — with a transposition of a hip, 9 — segmented; the dotted line showed position of a femur to an osteotomy.

At a bone anchylosis in vicious situation in a hip joint of O. carry out by Lorentz's method — Knysha: cut bone commissure between a femur and a basin on a contour of a head (fig. 1). Often apply intertrochanteric angular O. on the Turnip, at a cut after a section of a bone there is a good contact between fragments. Subtrochanterian cross O. on Ganta (fig. 2, 1) is applied seldom, however its modifications allow to compare densely fragments and to hold them in such situation. So, A. Hoffa offered linear slanting O. with implementation of a distal fragment in proximal (fig. 2, 2). O.'s kind on the Turnip in the form of hinged O. (fig. 2, 4) much more difficultly technically has also no advantages before angular (fig. 2, 3). At O. according to Kozlowski (fig. 2, 5) deduction of fragments is reached by intramedullary implementation bone and at that a transplant, across Kochev (fig. 2, 6) — strong mutual fixing of fragments is reached fenestrated by the Lake. At laminar subtrochanterian O. according to Kirchner — to Haas (fig. 2, 7) carry out 6 — 8 longitudinal sections of a bone on all thickness. At ankiloza in the provision of bending at an angle, close to 90 °, O. like transposition of a hip on Vincent's technique — Storm (fig. 2, 8) is preferable. Segmented O. across Bogoraz (fig. 2, 9) is shown at the ankylosed joint in vicious situation with shortening of a hip.

After O. the hip is established at an angle 170 ° (for persons of sedentary professions — at an angle 150 — 160 °), and assignment of a hip at women — within 10 — 15 ° from the centerline, at men — within 0 — 5 °.

Fig. 3. The diagrammatic representation of options of an osteotomy at chronic dislocation of a femur and other morbid conditions of a hip joint: 1 — an osteotomy across Kirmisson; 2 — an osteotomy according to Lorentz (the dotted line showed position of a femur before operation); 3 — an osteotomy on Shantsa with introduction to a bone of two metal cores connecting among themselves fixing a bone after an osteotomy; 4 — an osteotomy at a plow of valga (the deleted wedge is specified by an arrow); 5 — an osteotomy at coxa vara; 6 — an intertrochanteric osteotomy according to Mac-Marri at a fracture of a neck of a hip (after a section of a bone the hip is taken away and moved knutr — under the line of a change and a head of a hip).

At chronic dislocation of a hip O. across Kirmisson (fig. 3, 7) improved by A. Lorentz and Bayer (S. of Bayer) — the so-called vilkovaniye consisting in creation of a support of a hip in the field of a basin (fig. 3, 2) is shown. The same aims are pursued by O. on Shantsa (fig. 3, 3). At a plow of valga (fig. 3, 4), coxa vara (fig. 3, 5) deformation is eliminated with wedge-shaped O.

Chasto apply slanting intertrochanteric O. according to Mac-Marri (fig. 3, 6). This O.'s purpose at a change or a nearthrosis of a neck of a hip — transfer of load from the line of a change of a head of a hip, and at the deforming arthrosis — improvement of blood circulation of a head of a hip and its fuller immersion in an acetabular hollow that increases the area of load of a head of a hip. It creates for a head of a hip the best biomechanical conditions at loading that in combination with improvement of blood circulation leads to reduction of pains in a hip joint. Therefore intertrochanteric O. is called sometimes by medical (osteotomia medicata).

Fig. 4. The diagrammatic representation of options of an osteotomy throughout a diaphysis of a bone: 1 — across Bogoraz, 2 — on Shpringera with removal of two bone wedges (are shown separately), 3 — across Abrazhanov, 4 — across Hakhutov, 5 — on Bira, 6 — across Bogoraz. In provisions 3 — 6 — for lengthening of a bone.

At the expressed angular deformations of a diaphysis of a hip (or bones of a shin) make O. at the level of an osteocampsia. By the form sections of a bone of O. can be various — linear, wedge-shaped, angular etc. At a curvature of all diaphysis apply segmented O. across Bogoraz — throughout a curvature put several slanting sections (fig. 4, 1). At rachitic deformations of a tibial bone apply segmented O. on Shpringera with removal of two bone wedges (fig. 4, 2). Apply slanting, step or segmented O. at the level of a diaphysis (fig. 4, 3—6) to lengthening of a bone.

Fig. 5. The diagrammatic representation of options of an osteotomy at an anchylosis in a knee joint in the provision of bending or a flexion contracture for the purpose of correction of an axis of an extremity: 1 — a wedge-shaped osteotomy (the dotted line showed the deleted wedge); 2 — a metaplasia on Vredyona (the dotted line showed contours of bones).
Fig. 6. The diagrammatic representation of correction genu valgum and genu varum by means of an osteotomy of a femur and bones of a shin: 1, 5 — a linear osteotomy with implementation of a bone transplant in the form of a wedge (it is specified by an arrow); 2, 6 — a wedge-shaped osteotomy with removal of a bone wedge; 3, 7 — an angular osteotomy; 4, 8 - a zhelobkovy osteotomy.

The bone anchylosis in a knee joint in the provision of bending is eliminated with wedge-shaped O. in the area of the former joint (fig. 5, 1). At the flexion contracture in a knee joint which is not exceeding 135 ° at preservation of painless movements within 40 — 50 ° make O. on Vredena — a so-called metaplasia of a femur (see. Vredena of operation ), the keeping function of a joint (fig. 5, 2). At a curvature of an axis of a knee joint in the frontal plane (genu valgum, genu varum) different types of O. on a femur or bones of a shin (fig. 6) apply.

Cross O. across Makyyuin (fig. 7, 1) is used seldom, apply wedge-shaped O. (fig. 6, 2, 6) more often.

Widely use angular O. of epicondyles of a femur on the Turnip (fig. 6, 3). V. S. Shargorod-sky offered zhelobkovy O. (fig. 6, 4), at a cut carry out slanting linear O., then in a proximal fragment create a trench and in it implement a distal fragment. All types of the listed O. carry out and on a tibial bone (fig. 6, 5, 6, 7, 8) from preliminary cross O. heads in order to avoid an injury of a fibular nerve are 5 — 6 cm lower than a fibular bone.

Fig. 7. Diagrammatic representation of options of a nadlodyzhechny osteotomy of bones of a shin: 1 — linear with introduction of a bone transplant; 2 — wedge-shaped with removal of a bone wedge; 3 — angular; 4 — zhelobkovy.
Fig. 8. Diagrammatic representation of options of an osteotomy of a humeral bone: 1 — an angular osteotomy at the level of a surgical neck at incorrectly accrete change; 2 — an angular epicondylic osteotomy at cubitus varus.

Apply O. to correction of deformations of an ankle joint of a tibial bone in nadlody-zhechny area and a fibular bone is 5 — 6 cm higher. Use wedge-shaped, angular or zhelobkovy O. (fig. 7) more often.

At incorrectly accrete fractures of a neck of a humeral bone, and also concerning varus or valgus deformations in an elbow joint apply angular O. on the Turnip (fig. 8). The osteotomy of the distal end of bones of a forearm is applied seldom (see. Talipomanus ).

The lake of a basin and a backbone apply at nek-ry diseases in this area (see. Backbone , Taz , Hip joint ).

From O.'s complications suppuration of an operational wound, shift of fragments of a bone, the slowed-down their union, education is possible nearthrosis (see).



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Ya. B. Yudin.

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