Page 95 - ASOP ROT Study Guide

may be anticipated by electing to fuse the joint until the fifth decade and then performing a second operation
to "unpick" the arthrodesis and convert it to an arthroplasty. This double operation has proved to be
surprisingly effective for the hip, giving good return to function.

Joints that can be usefully fused are the ankle and the wrist. They are small joints making it easier to hold the
bone ends together. Also these are joints which are at present difficult to replace and which have a limited
range of functional movement in any case.

Fusion is however still a difficult option for patients, however logical the procedure. This is because patients
generally have unrealistic ideas of the effectiveness of arthroplasty.... "If we can go to the moon now - why do
you need to fuse my hip?"

Osteotomy consists of the surgical realignment of a joint. The aim of the operation is to redirect forces across a
joint so that they more evenly distribute the load to which the joint is subjected. Generally osteotomy is
performed where a joint has become deformed and the loads crossing it are distorted by the deformity. A
good example is at the knee where, if a person becomes bow legged, all the load passes down the medial
side of the joint rather than down the middle. Try standing bow legged and feel the strain on the inside of your
knees.

Where do you feel the strain when standing knock kneed?

FIGURE. Proximal tibial lateral closing
wedge (A) and medial opening wedge (B)
osteotomy to correct posttraumatic varus
deformity. Osteotomy location and wedge
size are selected to optimize healing across
a broad, cancellous surface and restore the
native mechanical axis..

https://www.jaaos.org/content/17/2/88/F1.expansion

Osteotomy is an option used widely hi the continent of Europe and with varying degrees of popularity in the
United Kingdom and America. This difference of attitude is traditional and otherwise impossible to explain.
Accurate surgical realignment is technically highly demanding and very time consuming. Perhaps the most
likely reason for its varying popularity is that widely differing results are achieved. Even in the best hands
osteotomy can only be viewed as a temporary measure lasting from one or two years to around ten. This is
because although a degree of correction may be achieved by surgery the basic underlying abnormality,
which is rarely understood, has not been tackled.

Osteotomy may be used to realign any deformity in any bone. For arthritis, osteotomy has been found
valuable in the young who have maintained a good range of movement, despite the pain which is typical of
the early stages of osteoarthritis. Conversely if the range of movement is severely limited then a simple
re-alignment is unlikely to succeed because useful function cannot be restored.

The hip and the knee are suitable for osteotomy, and we may use the hip joint as our example again.
Osteotomy may be performed on the pelvic side, either by forming a shelf or by total acetabular realignment.
It may be performed on the femoral side by altering the angle of the femoral neck to change the attitude of the
femoral head relative to the acetabulum.

In general terms osteotomy may be said to be a good operation in young people who have retained a good
range of motion, and have a reasonable preservation of articular cartilage