Osteotomy

Osteotomy is a procedure wherein a bone or a portion of the bone is cut. Osteotomy refers to a variety of bone cutting procedures that are used to correct deformity, relieve pain from arthritis and for cosmetic changes. It is an elective surgical procedure and is performed under general anesthesia. The damaged bone near the affected joint is removed surgically.

The bone is fixed by either cutting it short or lengthening it or correcting the damage. The damage may be caused by trauma, arthritis or growth abnormalities. Cutting through the bone allows repositioning of the bone thereby remodeling the appearance, position and transferring the point of stress. Osteotomy procedure helps in shifting the weight from the area of the damaged cartilage to the area where there is normal or healthy cartilage.

This surgical procedure is carried out mainly for the knee and the hip joints. Though any bone can be repaired or repositioned using this procedure, the list includes hands, vertebrae, arms, middle ear, hips, jaws, ankles, toes and shoulder blades.

Osteotomy corrects various deformities such as bow legs, knock knees and deformity of the big toe. This procedure is usually performed on those who have a broken bone that has healed crookedly Or when the bone plate experiences a trauma and heals unevenly. This procedure is effective only when one side of the joint is affected. People suffering from osteoarthritis often prefer an osteotomy over a total replacement of the joint.

• If osteotomy is performed on the inner knee, the surgeon removes the bone from the outer side of the tibia/large lower leg bone near the knee.
  
• Osteotomy of the hip includes removing bone from the femur/upper thigh bone.
  
• This procedure tilts the body weight of the person towards the healthier cartilage that is located on the outer knee.
  
• The weight is spread evenly across the joint cartilage.
  
• Once the bone wedge is removed, the remaining bones are secured with pins or staples.
  
• If the procedure is for the outer knee, the bone from the inner side of the lower leg is removed so as to shift the weight towards the inner knee.

Osteotomy helps in postponing joint replacement for a few years; this procedure is usually carried out on young people. Post surgery, for about 4-8 weeks a splint or cast is used to limit the movement. Once the cast is removed, physical therapy is advised for a few weeks. Post surgery - it may take up to 12 weeks for the person to apply complete weight on the joint and may take up to a year for the joint to adjust to the corrected position.

Blount Disease

Blount's disease or 'tibia vara,' is a growth disorder in the shin bone that affects the bones of the lower leg causing the lower leg to angle inward. This resembles a bow leg.

Named after the American orthopedic surgeon, Putnam Blount (1900 - 1992), Blount's disease is characterized by progressive lower limb deformity. Though Blount can affect people at any time during the growing process, it is more common in kids younger than four and in teens. A lot of pressure is put on the growth plate on the top of the tibia. This portion is called the physis - made out of cartilage, weaker than bone. The function of the physis is to allow the bone to lengthen and grow.

Due to excess pressure, the bone does not grow normally and instead the lateral outer side of the tibia keeps growing whereas the medial or inner side of the bone does not. Because of uneven bone growth, the tibia tends to bend outward instead of growing straight. Blount is not the same as naturally bowed legs that babies and toddlers have which usually straighten out when they start walking.

Blount is described as two distinct forms, early or infantile and late or adolescent Blount disease.

Infantile Blount disease is diagnosed between age one and three years. The disease presents when a child begins to ambulate. This disease is often bilateral and is less commonly associated with obesity.

Quite unlike the infantile Blount, late onset of Blount disease occurs in older children and is commonly associated with obesity and is often unilateral.

A combination of mechanical and biological factors influences Blount's disease to varying degrees. The mechanical forces contributing to the disease are weight of the child, age at walking, and varus deformity. The compressive forces across the medial femoral physis lead to growth retardation. Adolescent Blount does not appear to be progressive, or as common as the infantile form.

Causes

The cause of Blount disease remains controversial but it is mostly due to a combination of hereditary and developmental factors. There is increased incidence of the disease in overweight children who walk at an early age. Certain theories that mechanical overload of the proximal tibia contribute to Blount disease has been found. This mechanical overload is attributed to obesity and varus deformity. But this alone cannot be a cause as the disease is also noticed in children with normal weight.

Increasingly it is more common in people of African heritage, where kids start walking at an early age and whose family member might have had it. There is a genetic component to the disease as well, though a direct pattern of inheritance has not been clearly revealed. Hence, Blount is multifactorial and may differ in the early or late onset forms of the disease.

Symptoms

It is imperative to understand that Blount disease starts in early childhood or late teen years, the curve can get worse if not treated. Hence early diagnosis is important. The most obvious sign of Blount is bowing of the leg below the knee. While in young kids it is usually not painful, it teens it can be. It can feel like a growing pain in the knee area. The pain may come and go and many teens resort to over-the-counter pain relievers. As the lower leg bears the weight of the body, other problems such as rotation of the tibia are noticed. This causes a condition called in-toeing, wherein the feet point inward instead of straight out. Blount disease, over several years, can lead to arthritis of the knee joint and trouble walking. One leg may become slightly shorter than the other.

Diagnosis

If there is knee pain that seems to be getting worse and cannot be traced to an injury, then the doctor might possibly consider Blount. A complete physical examination will be done, and X-rays of legs taken. The doctor will look for any abnormal growth pattern at the top of the tibia - a tell tale sign of Blount. This will help the doctor measure how severe the bowing is.

Treatment

Treatment for Blount depends on the age of the patient and how far the disease has progressed. Young kids are advised braces, which are long-legged and lock the knee and need to be worn whilst weight bearing. But bracing is usually unsuccessful in girls and those with obesity. Older kids and teens will need surgery. There are different types of surgeries to correct Blount disease. These involve cutting the tibia, realigning it and holding it in place with plate and screws. This procedure is called Osteotomy. Sometimes, the damaged growth plate is removed and a device called external fixator is used to hold bones in place from the outside. In case of a twisted toe, surgeons correct the cause of it. Surgery is done under general anesthesia, and the patient might wear a cast and use crutches for a while. Physical therapy will be needed after surgery.

Clinodactyly

Clinodactyly is derived from the Greek 'klinein' which means to bend, slope or incline and 'dactylos' which is finger, toe. Clinodactyly is a condition describing a bend or curvature of the fifth fingers, the little fingers, toward the adjacent fourth or the ring fingers. It is sometimes called '"fifth finger clinodactyly' to distinguish it from similar curving of other finger or toe. It is a minor congenital isolated anomaly which goes unnoticed most of the times. It can also occur in combination with other abnormalities in many genetic syndromes such as Russell-Silver syndrome or Down Syndrome (trisomy 21) and Klinefelter (XXY) syndrome, Banki syndrome, Blooms syndrome and Feingold syndrome.

Clinodactyly can be identified in prenatal ultrasound. It is statistically correlated with increased risk of chromosome aberration in the fetus. Clinodactyly is also diagnosed by treating physicians after a thorough medical history and careful physical examination. X rays are used to confirm the diagnosis. As such no treatment is required for clinodactyly. Some surgical procedures involve an osteotomy, making a cut in the bone and correcting the deformity, and stabilizing the finger until the bone and soft tissue are healed. Although surgery is usually successful in correcting this condition, there is a always a risk of recurrence and need for future surgery.

The exact incidence of clinodactyly is not known but it is estimated to be present in approximately 10% of the general population. It occurs in 60% of patients with Down Syndrome. If the condition is noted during a prenatal ultrasound, then amniocentesis may be warranted. Interestingly, clinodactyly can be an inherited condition as well, and may be present as a part of an associated syndrome.