Planning in The Critical Situation

The very first step for preparing a layout of a pre-operative plan is the drawing of the outline of the AP and the lateral x-ray of the normal side. One will have to mark the joint axis and the anatomical axis shown on the AP and the lateral x-ray and if feasible, the mechanical axis in the lower extremity.

The next step is of marking out the outlines of the AP and lateral x-ray of the damaged bone. Then obtain the angle of correction directly by superimposing the tracing of the normal side over the tracing of the deformed side and by tracing in the normal anatomical axis on the deformed side. Now one has to find out the intersecting point of the anatomical axis of the normal side and anatomical axis of the deformed side. This intersection of both the axis is the angle of correction.

However, it is very challenging to draw the anatomical axis in case of complex deformity due to the distorted bone. So in such condition, superimposing of the tracing of the abnormal side over the tracing of the normal bone can be useful. One is to start with the distal part or proximal of the bone after that draw in the anatomical axis of the normal side onto the deformed side by superimposing the joint surfaces and as much of the metaphysis feasible. Thus, one can be able to determine the proximal and distal anatomical axis of the deformed bone. Now one will obtain the intersecting point of both the axis by extending them. Through this intersecting point one can find out the angle of correction. It is extremely difficult to draw in the rotational deformity, but the degrees of improper rotation should be marked in on the pre-operative plan. The similar procedure is repeated for the lateral projections.

Former trends in the correction

However, the best way to correct an angular deformity of long bone is by means of the apex of the deformity. But in former times, surgeons used to correct diaphyseal angular deformities through the metaphysis, expecting desirable recovery from the cancellous bone. But this kind of correction practice specifically the corrective osteotomy could not serve the purpose and filed. Such corrections gave rise to new more complicated deformities which hardly deal with the problem they were expected to correct. This resulted in more intricate and serious problems to deal with. An unacceptable angulation of weight-bearing surface might be incorporated in these corrections, which was earlier at 90 to the weight-bearing axis or in an undesirable relocation of the bone which gave way to the undesirable abnormal loading of the joints.

Type of osteotomy to be carried out

While planning a corrective osteotomy, the most possible and practicable corrections must be apprehended by a surgeon. A number of possibilities are there in correction deformities.

• Angular corrections can be carried outin the coronal and sagittal planes.
• One can rotate in or out, shorten or lengthen, and finally relocate medially, laterally, anteriorly, or posteriorly.
• Cuts in osteotomy can be stepwise, transverse or oblique.
• If a rotational correction is required, it is good to begin with a transverse osteotomy at 90° to the long axis of the bone. This will allow rotational corrections no matter of what wedges are cut from the another fragment.
• Whenever the initial cut is oblique, one strives for the correction of a rotational deformity, but may end up with the very inconvenient task of having to cut a pyramidal wedge proximal femoral nail antirotation.
• While correcting angular deformities the surgeon must take into consideration that the wedges can be either open or closed, depending on whether one desires to shorten or lengthen the bone. Closing wedges unite faster and hardly need bone grafting, but they have to renounce the length.
• Opening wedges adds to length, but it is best to reserve them for children and adolescents. Since they heal at a slow speed in adults or do not heal at all. Such defects can be corrected through grafting. Allograft blocks can be used if required.

To some extent proximal femoral nail antirotation, same discretions can be applied to the mode of fixation in the following ways:

• If plate fixation is planned, Opening wedges of diaphysis in the adult should not be attempted.
• If an proximal femoral nail antirotation for fixation is used and if with an intramedullary saw is used in while carrying out the osteotomy, leaving the soft-tissue envelope undisturbed, generally, the result is good healing without further requirement of bone grafting. However, an opening wedge in which a plate might be used over a block allograft can be an exceptional.
• The Ilizarov technique is very helpful in continuous corrections of complicated deformities. But the principles of this technique is quite different from the first one. So the two must not be mixed up.

Progressive corrections of complex deformities are possible with the Ilizarov technique. The principles of such corrective procedures are different and the two techniques should not be confused proximal femoral nail antirotation.

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