Osteotomy: Types, Symptoms, Causes, Diagnosis & Recovery

Here are the different types of osteotomies:

1. Lower Limb Osteotomies

• Tibial Osteotomy: This is the most common osteotomy for knee osteoarthritis. There are two main approaches:

  • Closing Wedge Osteotomy: A wedge of bone is removed from the lateral (outer) side of the tibia, effectively bringing the leg bone inward and redistributing weight to the less damaged inner portion of the knee joint.

  • Opening Wedge Osteotomy: A wedge-shaped bone graft is inserted on the medial (inner) side of the tibia, pushing the leg bone outward and again shifting weight distribution.

• Femoral Osteotomy: Less common than tibial osteotomy for knee issues, femoral osteotomy targets the thigh bone. It's typically used for severe osteoarthritis affecting the outer compartment of the knee. There are two primary variations:

  • High Femoral Osteotomy (HTO): A wedge of bone is removed above the knee joint, realigning the femur and reducing stress on the outer portion.

  • Distal Femoral Osteotomy (DFO): The cut is made just above the knee joint, with a similar goal of correcting leg alignment and alleviating pressure on the outer compartment.

2. Pelvic Osteotomies

• Pelvic Periacetabular Osteotomy (PAO): This procedure focuses on the acetabulum (hip socket) and is used to correct hip dysplasia, a condition where the socket doesn't fully cover the femoral head (ball of the femur). The surgeon cuts and repositions the bony socket to improve coverage and stability of the hip joint.

• Femoral Varus/Valgus Osteotomy: This osteotomy corrects bowing deformities in the femur. A wedge of bone is removed (varus) or added (valgus) to straighten the leg and improve hip mechanics.

3. Spinal Osteotomies

• Spinal Fusion with Osteotomy: This combines spinal fusion, where vertebrae are permanently joined, with an osteotomy to correct spinal curvatures. Different types of osteotomies can be used depending on the curvature:

  • Posterior Spinal Osteotomy (PSO): Used for kyphosis (hunchback), a wedge of bone is removed from the back of the spine to straighten it.

  • Anterior Spinal Osteotomy (ASO): For severe kyphosis, this procedure involves removing a wedge from the front of the spine.

  • Vertebral Body Wedge Resection: This targets specific vertebrae in cases of scoliosis (curvature of the spine). A wedge of bone is removed from the convex (outward) side of the curve to straighten the spine.

4. Upper Limb Osteotomies

• Humeral Osteotomy: This procedure corrects deformities or malunions in the humerus (upper arm bone). The type of osteotomy depends on the specific issue.

5. Jaw Osteotomies

• Mandibular Osteotomy: This surgery focuses on the lower jaw (mandible) and is used for various reasons, including correcting an overbite, underbite, or asymmetry. The surgeon cuts and repositions the lower jawbone to achieve the desired facial profile and functional bite.

• Maxillary Osteotomy: This procedure targets the upper jaw (maxilla) and is less common than a mandibular osteotomy. It may be used to address severe overbites or midface deficiencies.

6. Foot and Ankle Osteotomies

• Chevron and Akin Osteotomies: These procedures correct mild to moderate bunion (hallux valgus) deformities. A wedge of bone is removed or repositioned at the base of the big toe to realign it.

• Dwyer Osteotomy: This osteotomy reshapes the midfoot to address an abnormally high arch (pes cavus). A wedge of bone is removed from the top of the foot to create a more neutral arch.

• Weil Osteotomy: This procedure corrects claw toe deformity and pain under the ball of the foot. A wedge of bone is removed from the middle phalanx of the affected toe to improve alignment.

• Cotton Osteotomy: This osteotomy helps create an arch in a flat foot (pes planus). A wedge of bone is removed from the inner aspect of the midfoot and the foot is repositioned to create an arch.

A dislocated kneecap (patella) can be a very dramatic and painful experience. Here's a detailed breakdown of the potential symptoms to watch out for:

• Sudden, Severe Pain: This is often the first and most noticeable symptom. The pain can be sharp and debilitating, making it difficult to put any weight on the affected knee.
• Loss of Movement: The dislocated kneecap can physically block the joint's normal range of motion. You might be unable to fully straighten or bend your knee, and any attempt to move it could cause intense pain.
• Feeling of Instability: The knee joint may feel loose or "out of place." This can be a frightening sensation, as it highlights the abnormal position of the kneecap.
• Visible Deformity: In some cases, the dislocated kneecap will be visibly out of its normal position. You might see a bulge or a noticeable misalignment on the front of the knee.
• Swelling and Bruising: The area around the kneecap will likely swell rapidly due to inflammation and internal bleeding. Bruising may also appear within a few hours of the dislocation.

Patellar dislocation, the popping out of the kneecap from its groove, can occur due to a combination of anatomical factors, injuries, and muscle imbalances. Here's a deeper dive into the potential causes:

Anatomical Predisposition

• Shallow Trochlear Groove: The trochlea is the groove at the lower end of the femur where the kneecap sits. A naturally shallow trochlea can provide less stability for the kneecap, increasing the risk of it dislocating laterally (outward).
• Patellar Alta: This refers to a kneecap that sits higher than normal on the femur. A high kneecap may track improperly and be more prone to dislocating.
• Ligament Laxity: Ligaments are strong tissues that connect bones and provide stability to joints. Loose or weak ligaments, particularly the medial patellofemoral ligament (MPFL) on the inner side of the knee, can't adequately hold the kneecap in place.
• Q-Angle Abnormality: The Q-angle is formed by the line drawn from the centre of the kneecap to the centre of the patellar tendon and another line drawn from the centre of the kneecap to the bony bump at the top of the shinbone (tibial tubercle). An increased Q-angle (greater than 15 degrees) can pull the kneecap outward, making it more susceptible to dislocation.

Injury

• Direct Blow: A forceful impact to the front of the knee, such as from a fall or collision, can dislocate the kneecap.
• Sudden Twisting: This is a common cause, particularly in sports activities that involve rapid changes in direction. When the foot is planted and the knee is fixed, a sudden twisting motion can put immense stress on the knee joint, forcing the kneecap out of place.
• Hyperextension: Overextending the knee beyond its normal range of motion can stretch or tear the ligaments, increasing the risk of dislocation.

Muscle Imbalances

• Weak Quadriceps: The quadriceps muscles at the front of the thigh are responsible for extending the knee and stabilising the kneecap. Weakness in these muscles can allow the kneecap to track improperly and become more vulnerable to dislocation.
• Tight Hamstrings: Tight hamstring muscles in the back of the thigh can pull the knee joint backward, putting undue stress on the patellar tracking and potentially contributing to dislocation.

While osteotomy offers potential benefits for various bone and joint issues, it's important to understand the potential risks involved. Here's a deeper dive into the key risk factors associated with osteotomy surgery:

Infection: Like any surgery, osteotomy carries a risk of infection at the incision site. This can range from a mild skin infection to a more serious bone infection. Factors that can increase the risk of infection include:

• Pre-existing medical conditions: Diabetes, obesity, and a weakened immune system can all make you more susceptible to infection.
• Poor nutrition: Proper nutrition is essential for healing, and deficiencies in certain vitamins and minerals can hinder the healing process and increase the risk of infection.
• Length of surgery: Longer surgeries generally have a higher risk of infection compared to shorter procedures.
• Smoking: Smoking constricts blood vessels, which can impair healing and increase the risk of infection.

Bleeding: Excessive bleeding during or after surgery is a potential risk. This can be due to factors like:

• Blood clotting disorders: Individuals with conditions like haemophilia or those taking blood thinners may experience increased bleeding.
• Damage to blood vessels: During surgery, there's a slight chance of accidentally damaging blood vessels, which can lead to bleeding.

Nonunion: This refers to a situation where the bone fails to heal properly after the osteotomy. Several factors can contribute to nonunion, including:

• Poor blood supply: The bone needs a good blood supply to heal properly. Conditions like diabetes or peripheral artery disease can limit blood flow to the area, increasing the risk of nonunion.
• Smoking: As mentioned earlier, smoking can hinder healing and increase the risk of nonunion.
• Infection: An infection at the surgical site can disrupt the healing process and lead to nonunion.
• Nutritional deficiencies: Deficiencies in vitamin D, calcium, and protein can all impair bone healing.
• Technical issues: Sometimes, technical challenges during surgery can affect the stability of the osteotomy, potentially leading to nonunion.

Hardware Failure: Plates, screws, or wires used to hold the bone in place after osteotomy can loosen or break over time. This can happen due to:

• Malpositioning of hardware: If the hardware isn't positioned correctly during surgery, it may put undue stress on the bone and increase the risk of failure.
• Metal fatigue: Over time, the metal hardware can fatigue and break, especially in younger, more active patients.
• Bone loss: Osteoporosis or other conditions that weaken the bone can increase the risk of hardware failure.

Blood Clots: Osteotomy, especially surgery on the legs, can increase the risk of developing blood clots in the deep veins (deep vein thrombosis, DVT). Blood clots can be dangerous and travel to the lungs (pulmonary embolism), potentially causing life-threatening complications. 

Patellar dislocation, while not directly related to osteotomy surgery, is a concern for those interested in knee health. Here are some strategies to help prevent a dislocated kneecap:

• Quadriceps Strengthening: The quadriceps muscles at the front of the thigh play a crucial role in stabilising the kneecap. Exercises like straight leg raises, squats, and lunges can be incorporated into a regular workout routine.
• Hamstring Flexibility: Tight hamstrings can pull the kneecap out of alignment. Stretching exercises like hamstring curls and toe touches can help improve flexibility.
• Hip Strengthening: Strong hip muscles improve overall leg stability and reduce stress on the knees. Exercises like side leg raises and glute bridges can be beneficial.
• Balance exercises: Activities like single-leg stands, wobble boards, and tai chi can improve proprioception (body awareness) and help maintain proper knee alignment during movement.
• Plyometrics (with caution): Low-impact plyometric exercises like box jumps or squat jumps can improve dynamic stability, but should be attempted with proper form and under the guidance of a qualified professional, especially for those with a history of knee issues.
• Knee Bracing: A properly fitted knee brace can provide support and proprioception cues to the joint, potentially helping to prevent dislocation during activities that put stress on the knee. Consult with a doctor or physical therapist to determine the right type of brace for your needs.
• Proper Footwear: Opt for shoes with good arch support and a stable sole to prevent rolling inwards (pronation) which can contribute to patellar instability.
• Maintain a Healthy Weight: Excess weight puts additional strain on the knees, increasing the risk of dislocation.
• Warm-Up and Cool-Down: Before engaging in physical activity, perform dynamic stretches to warm up the muscles and joints. Similarly, cool down with static stretches afterwards to improve flexibility and prevent injury.

Diagnosing a patellar dislocation typically involves a combination of a physical examination, medical history, and sometimes imaging tests. Here's a breakdown of the process:

Physical Examination

• Inspection: The doctor will visually inspect the knee for swelling, bruising, deformity, and any visible signs of the kneecap being out of place.
• Palpation: The doctor will feel around the knee joint to assess for pain, tenderness, and instability of the kneecap.
• Range of Motion: The doctor will check your ability to bend and straighten your knee to assess joint function.
• Stress Tests: Specific tests may be performed to assess ligament stability around the kneecap, such as the apprehension test or the drawer test.

Medical History

The doctor will discuss your symptoms, including:

• When the injury occurred
• The mechanism of injury (how it happened)
• The severity of the pain
• Whether you've experienced any previous knee dislocations
• Any other relevant medical history

Imaging Tests

Imaging tests are not always necessary for diagnosing a straightforward patellar dislocation, but they may be used to:

• X-ray: X-rays can confirm the patellar dislocation and rule out any bone fractures.
• MRI Scan: An MRI scan provides detailed images of the soft tissues around the knee joint, including ligaments, tendons, and cartilage. This can be helpful in identifying any associated ligament tears or cartilage damage.

An osteotomy typically involves several stages, from pre-operative preparation to post-surgical recovery. Let's delve deeper into each stage:

Pre-operative Stage

1. Consultation and Diagnosis: This initial stage involves consulting your doctor or orthopaedic surgeon. They will review your medical history, symptoms, and X-rays or MRIs to determine if osteotomy is the right treatment for you.
2. Planning and Preparation: Once osteotomy is chosen, your surgeon will discuss the specific type of procedure needed, the type of anaesthesia used, and potential risks and benefits. They will also guide you through pre-operative instructions, which may include stopping certain medications, fasting beforehand, and arranging for transportation after surgery.

Surgical Stage

1. Anaesthesia: General anaesthesia is typically used for osteotomy, meaning you'll be unconscious throughout the procedure. In some cases, regional anaesthesia may be used, which numbs the area around the surgery while you remain awake.
2. Incision: The surgeon will make an incision over the affected bone, allowing them to access the surgical site. The size and location of the incision will vary depending on the type of osteotomy being performed.
3. Bone Cutting: Using specialised surgical tools, the surgeon will precisely cut the bone according to the planned correction. The type of cut will depend on the specific procedure. For example, in a tibial osteotomy for knee osteoarthritis, a wedge of bone might be removed (opening wedge) or inserted (closing wedge) to realign the leg.
4. Bone Fixation: After the bone is cut and repositioned, the surgeon will use various implants to hold it in place and promote healing. These implants might include plates and screws made of metal or biocompatible materials.
5. Wound Closure: Once the bone is secured, the surgeon will meticulously close the surgical incision with sutures or staples.

Post-operative Stage

1. Recovery Room: Following surgery, you'll be monitored in the recovery room for several hours as you wake from anaesthesia.
2. Pain Management: Pain medication will be administered to manage post-operative discomfort.
3. Physical Therapy: A physical therapist will work with you to gradually regain strength, flexibility, and range of motion in the affected joint. This may involve exercises focused on strengthening the muscles around the joint and improving your gait.
4. Wound Care: The surgical team will provide instructions on caring for your incision site to prevent infection and promote healing.
5. Follow-Up Appointments: Regular follow-up appointments with your surgeon are crucial to monitor your progress, assess healing, and address any concerns you may have.

The road to recovery after osteotomy surgery varies depending on the specific procedure performed, the severity of the condition being addressed, and your individual healing rate. However, there are some general steps you can expect to follow:

Immediately After Surgery

• Pain Management: Your doctor will prescribe pain medication to help manage discomfort in the initial days following surgery.
• Immobilisation: Depending on the type of osteotomy, you might be fitted with a cast, splint, or brace to immobilise the joint and promote healing.
• Weight Bearing: Your doctor will determine the appropriate weight-bearing restrictions. Some procedures might allow partial weight bearing with crutches initially, while others may require non-weight bearing for a period.
• Physical Therapy: A physical therapist will guide you through gentle exercises to improve range of motion, reduce swelling, and strengthen the muscles around the joint.

The First Few Weeks

• Gradual Increase in Activity: As pain subsides and healing progresses, your physical therapist will gradually increase the intensity and complexity of your exercises. These exercises will focus on regaining strength, flexibility, and balance.
• Swelling Management: Elevation and ice therapy will continue to be important for reducing swelling and promoting healing.
• Pain Medication: You may be able to gradually transition from prescription pain medication to over-the-counter pain relievers as your discomfort lessens.

Weeks 4-8

• Increased Mobility: By this stage, you should be able to walk with more confidence, potentially without crutches depending on the procedure.
• Strengthening Exercises: Your physical therapy program will focus on building muscle strength and endurance to support the repaired joint.
• Return to Work: Depending on your job and the type of osteotomy performed, you might be able to return to work with some modifications during this period.

Months 2-6

• Continued Physical Therapy: Physical therapy sessions will likely become less frequent, but they remain crucial for maintaining progress and preventing complications.
• Gradual Return to Activities: As your strength and flexibility improve, you can gradually resume activities you enjoy, but with caution and doctor's approval. High-impact activities might need to be delayed for a longer period.

Beyond 6 Months

• Maintenance Exercises: Maintaining a regular exercise routine that incorporates strength training and flexibility exercises is crucial to protect the repaired joint and prevent future issues.
• Long-Term Follow-up: Regular check-ups with your doctor will allow them to monitor your progress and address any concerns.

1. What is osteotomy?
   Osteotomy is a surgical procedure that involves cutting and reshaping bones to correct deformities, realign joints, or alter the bone's alignment.
2. Why is osteotomy performed?
   Osteotomy is performed to correct deformities, such as those caused by osteoarthritis, congenital abnormalities, or trauma, and to improve joint function and relieve pain.
3. What conditions can be treated with osteotomy?
   Osteotomy can be used to treat conditions such as osteoarthritis, malunited fractures, knee deformities, hip dysplasia, and other joint-related issues.
4. How is osteotomy different from arthroplasty?
   Osteotomy involves cutting and reshaping bones, while arthroplasty involves replacing or reconstructing the entire joint.
5. Is osteotomy a major surgery?
   Yes, osteotomy is considered a major surgery because it involves cutting and realigning bones, and it requires general anaesthesia.
6. What are the risks associated with osteotomy?
   Risks of osteotomy include infection, bleeding, nerve damage, blood clots, nonunion of bone, and the need for further surgery.
7. How long does it take to recover from osteotomy?
   Recovery time varies depending on the type and extent of the osteotomy, but it generally takes several weeks to months to fully recover.
8. Will I need physical therapy after osteotomy?
   Yes, physical therapy is usually recommended after osteotomy to help regain strength, flexibility, and range of motion in the affected joint.
9. Can osteotomy be performed on any bone in the body?
   Osteotomy can be performed on many bones in the body, including the femur, tibia, hip, knee, and ankle, among others.
10. How long does the procedure take?
    The duration of the osteotomy procedure depends on various factors such as the complexity of the surgery and the specific bone being operated on, but it typically takes a few hours.
11. Is osteotomy painful?
    Pain during and after osteotomy can be managed with pain medications prescribed by your doctor.
12. How long do the results of osteotomy last?
    The results of osteotomy can be long-lasting, but it depends on factors such as the underlying condition being treated and the patient's adherence to post-operative care and rehabilitation.
13. Can osteotomy be performed on children?
    Yes, osteotomy can be performed on children, especially to correct congenital deformities or growth abnormalities.
14. Will I need to wear a cast after osteotomy?
    Whether a cast is required after osteotomy depends on the specific procedure and your surgeon's recommendations.
15. How soon can I return to work after osteotomy?
    The timing for returning to work varies depending on the type of work you do and the extent of the osteotomy. Your surgeon will provide guidance on when it's safe to return to work.
16. Can osteotomy be done laparoscopically?
    Yes, some osteotomy procedures can be performed laparoscopically, using small incisions and specialised instruments.
17. Will I be able to walk immediately after osteotomy?
    In some cases, patients may be able to walk with assistance shortly after surgery, while in others, weight-bearing may be restricted for a period of time.
18. What type of anaesthesia is used for osteotomy?
    Osteotomy is typically performed under general anaesthesia, although regional anaesthesia may be used in some cases.
19. Can osteotomy be done as an outpatient procedure?
    Some minor osteotomy procedures may be done on an outpatient basis, while more complex surgeries may require hospitalisation.
20. How do I prepare for osteotomy surgery?
    Your surgeon will provide specific instructions for preparing for osteotomy surgery, which may include fasting before surgery, stopping certain medications, and undergoing preoperative tests.
21. Will I have scars after osteotomy?
    Scarring after osteotomy is unavoidable, but the extent of scarring depends on factors such as the surgical technique used and your body's healing response.
22. Can osteotomy be reversed?
    In some cases, osteotomy may be reversible, but it depends on the specific circumstances and the extent of the initial surgery.
23. How much does osteotomy surgery cost?
    The cost of osteotomy surgery varies depending on factors such as the location, hospital fees, surgeon's fees, and any additional procedures or tests required.
24. Are there any dietary restrictions after osteotomy?
    Your surgeon may recommend dietary restrictions, especially if you're taking medications that can affect digestion or if you have specific nutritional needs for bone healing.
25. Can osteotomy be performed on elderly patients?
    Yes, osteotomy can be performed on elderly patients, but the decision depends on factors such as overall health, bone density, and the ability to withstand surgery and rehabilitation.
26. What are the alternatives to osteotomy?
    Alternatives to osteotomy include conservative treatments such as medication, physical therapy, and assistive devices, as well as more invasive procedures like joint replacement.
27. How long do I need to stay in the hospital after osteotomy?
    The length of hospital stay after osteotomy varies depending on factors such as the type of surgery performed and your overall health, but it's typically a few days to a week.
28. Will I need to use crutches or a walker after osteotomy?
    Your need for crutches or a walker after osteotomy depends on factors such as the extent of the surgery and your ability to bear weight on the affected limb.
29. Can osteotomy be performed on patients with osteoporosis?
    Osteotomy can be performed on patients with osteoporosis, but extra precautions may be necessary to ensure bone healing and stability.
30. How soon can I drive after osteotomy?
    Your surgeon will advise you on when it's safe to resume driving after osteotomy, which may depend on factors such as the type of surgery and your ability to control the vehicle.
31. Are there any long-term complications of osteotomy?
    Long-term complications of osteotomy can include arthritis, joint stiffness, recurrence of deformity, and impaired function of the affected limb.
32. Can osteotomy be performed on athletes?
    Yes, osteotomy can be performed on athletes, but the decision depends on factors such as the type of sport played and the extent of the deformity or injury.
33. Will I need assistive devices at home after osteotomy?
    Your need for assistive devices at home after osteotomy depends on factors such as the extent of the surgery and your ability to perform daily activities independently.
34. How often will I need follow-up appointments after osteotomy?
    You will likely need regular follow-up appointments with your surgeon to monitor your progress, assess healing, and address any concerns or complications.
35. Can osteotomy be performed on obese patients?
    Osteotomy can be performed on obese patients, but extra precautions may be necessary to ensure surgical success and minimise complications.
36. Can osteotomy be performed on patients with diabetes?
    Osteotomy can be performed on patients with diabetes, but careful management of blood sugar levels and wound care is essential to promote healing and prevent complications.
37. How much bone is typically removed during osteotomy?
    The amount of bone removed during osteotomy varies depending on the specific condition being treated and the surgical technique used. It can range from a small wedge to a larger segment of bone.
38. Will I need to wear a brace after osteotomy?
    Your surgeon may recommend wearing a brace after osteotomy to provide support and stability to the affected joint during the initial stages of healing.
39. Can osteotomy be performed on patients with rheumatoid arthritis?
    Osteotomy can be performed on patients with rheumatoid arthritis, but careful consideration is given to the inflammatory nature of the disease and its potential impact on bone healing.
40. Can osteotomy be combined with other procedures?
    Yes, osteotomy can be combined with other procedures such as ligament repair, cartilage restoration, or joint replacement, depending on the specific needs of the patient.
41. How soon can I resume physical activities after osteotomy?
    The timing for resuming physical activities after osteotomy varies depending on factors such as the type of surgery performed and your surgeon's recommendations. Generally, it's a gradual process guided by your rehabilitation program.
42. Will I need to take antibiotics after osteotomy?
    Your surgeon may prescribe antibiotics after osteotomy to prevent infection, especially if you have risk factors such as diabetes or a weakened immune system.
43. Can osteotomy be performed on patients with haemophilia?
    Osteotomy can be performed on patients with haemophilia, but careful management of bleeding risks is essential to minimise complications.
44. Can osteotomy be performed on patients with metal implants from previous surgeries?
    Yes, osteotomy can be performed on patients with metal implants from previous surgeries, but the presence of implants may affect the surgical approach and technique.
45.  Will I need imaging tests before osteotomy?
    Your surgeon may order imaging tests such as X-rays, CT scans, or MRI scans before osteotomy to assess the extent of the deformity and plan the surgical approach.
46. Can osteotomy be performed on patients with bone infections?
    Osteotomy can be performed on patients with bone infections, but careful management of the infection is essential to prevent its spread and promote healing.
47. How soon can I shower after osteotomy?
    Your surgeon will provide specific instructions on when it's safe to shower after osteotomy, typically once the incisions have healed and any dressings or sutures have been removed.
48. Can osteotomy be performed on patients with autoimmune diseases?
    Osteotomy can be performed on patients with autoimmune diseases, but careful coordination with specialists may be necessary to manage potential complications related to the underlying condition.
49. Will I need to stop smoking before osteotomy?
    Your surgeon may recommend quitting smoking before osteotomy because smoking can impair bone healing and increase the risk of complications such as infection.
50. Can osteotomy be performed on patients with a history of joint dislocations?
    Osteotomy can be performed on patients with a history of joint dislocations. Still, careful assessment of ligament and soft tissue integrity is essential to ensure joint stability and function post-surgery.