Hello and welcome to the Young Orthopod.

Today we will discuss about the basics of Osteotomy,

knowledge of the limb axis and the relation to the joints, it is the foundation of analyzing the skeletal
deformity. Each long bone has an anatomic and mechanical axis. The anatomic axis of the long bone is the
line that passes through the centre of diaphyses along the length of the bone. In the normal bone, the
anatomic axis is a single straight line. In a malunited bone with angulation, each bony segment can be
defined by its own anatomic axis. The mechanical axis of the bone is defined as the straight line connecting
the joint centrepoints of the proximal and distal joint. The hip joint centre is located at the centre of the
femoral head. The knee joint centre corresponds to the midpoint between the tibial spines on the tibial
plateau line and the apex of the intercondylar notch on the femoral articular surface. The ankle joint
centre is the centre of the tibial plafond. A line can also represent the orientation of a joint in a particular
plane or projection. Joint orientation describes the relation of a joint with respect to its anatomic and
mechanical axis of a long bone. The angle formed between the joint orientation line and either the
mechanical or the anatomic axis is called the joint orientation angles.

The point at which the proximal and distal axis length of the deformed bone intersects is called the Centre
Of Rotation of Angulation or popularly known by the acronym CORA. It is a point about which a deformity
may be rotated to achieve correction. The angle formed by the two axis at the CORA is the measure of the
angular deformity in that plane. CORA indicates whether an axis of rotation named the Angulation
Correction Axis or the ACA should be placed, about which the two intersecting axis of the CORA can be
brought in line, hence the deformity corrected. The bisector is a line that passes through the CORA and
bisects the angle formed by the proximal and distal axis. Angular correction along the bisector results in
complete deformity correction without the introduction of translation in deformity. The collinear
realignment of the proximal and distal axis occurred whenever the ACA is matched to any point on the
bisector of an angular deformity. Thus CORA can also be defined as any point that will lead to collinear
realignment of the bone axis when the ACA passes through it. Therefore all the points on the bisector can
be considered CORAs. If CORA is found to be proximal or distal to the apex of angulation, but within the
boundaries of the bone, that suggest the presence of translation as the additional component of the
deformity, the rotation axis to enable the correction should be maintained on the bisector of the CORA
but the osteotomy can be sited either at the apex of angulation or at the same level as the CORA. When
the osteotomy is on the apex of the deformity, correction of both the translation and angulation is
simultaneously accomplished at the site of the original deformity. But when the osteotomy is sited on the
CORA, a new deformity is created which correctly balances the malalignment produced from the original
site.

If the CORA lies outside the point of obvious deformity, either a second CORA exist in that plane and the
deformity is multi-apical or a translational deformity exist in that plane. This kind of deformity would need
multiple osteotomies.

In the osteotomy line, and the ACA pass through the same CORA, the bone ends would angulate in relation
to each other without displacement or translation. The axis of the bone proximal and distal to the
osteotomy level will become collinear when the magnitude of the angulation is corrected.

If the ACA passes through the CORA but the osteotomy does not pass through this point, the bone ends
at the osteotomy level will both angulate and translate to each other.

If the ACA does not pass through a CORA on the bisector, the proximal and distal axis of the bone would
be balance But translated to each other when the magnitude of angulation is corrected.
The point at which the transverse bisector line intersects the convex cortex is called the opening wedge
CORA. The osteotomy line also passes through this point, the convex cortex remains in contact and there
is a wedge-shaped bone defect with the space at the concave side. The final length of the bone is at the
convex cortex. All the points on the convex side of the ACA CORA will be compressed whereas all the
points on the concave side will be distracted.

The point at which the transverse bisector line intersects the concave cortex is called the closing wedge
CORA. If the osteotomy and the ACA passes through this point, a closing-wedge correction results. The
closing wedge osteotomy requires removal of bone to allow angular correction, and there is full bone-to-
bone contact at the end of the correction. The final length of the bone is shorter than in the opening
wedge type and is equal to the length of the concave cortex.

The CORA which is between the convex and concave cortices on the transverse bisector line is called the
neutral wedge CORA. If the osteotomy and the ACA passes through this point, partial opening and partial
closing wedge correction results. Half the wedge is removed and half the wedge is open. Neutral wedge
osteotomy has no effect on the bone length.

As we discussed earlier, if the osteotomy is made at the different level from that of the CORA on the
bisector line, and the angular correction is performed on the point of osteotomy line, a translational
deformity is produced. The amount of translation is greater for opening than for a closing wedge
osteotomy.

If the opening or closing wedge osteotomy is made through the opening or closing wedge point,
irrespectable the orientation of osteotomy, no translation deformity will arise. A bump in concavity may
arise as a consequence of inclination of osteotomy site in the opening wedge corrections, and as a defect
in closing wedge corrections.

An alternative to the straight osteotomy, is a circular shaped dome osteotomy. It is actually a cylindrical-
shaped cut in 3-dimension. The focal dome osteotomy is a cylindrical or circular-shaped bone cut with
which the CORA corresponds to the centre of the circular cut. For each CORA, there are circular cut of
different radii that can be made. The limiting factor is the amount of bone-to-bone contact at the
osteotomy length. The larger the radius of the focal dome osteotomy, the more translation and the less
bone contact. Beyond a certain radius, this becomes impractical. If the central axis of the dome osteotomy
does not corresponds to the CORA on the bisector line, a secondary translational deformity at the axis of
the bone is produced and the deformity is corrected.

Focal dome osteotomy can be made at the CORA regardless of whether closing, neutral, or opening wedge
procedure are being performed. As with the straight-cut, closing, neutral or opening wedge osteotomy,
there is a similar change in the length of the bone with the corresponding focal dome osteotomy, so this
is all about the basics of osteotomy.