Indications for bone osteotomy and possible complications of the operation. Algorithm for choosing a treatment method for MVO lesions

Anatomy of the elbow joint

The elbow joint is formed by the distal humerus and the proximal radius and ulna. It is very important that each bone clearly and evenly forms the elbow joint so that the load during movements is distributed evenly and there is no pathological shift of the load from one edge to the other.

Short radius syndrome disrupts the balance of the joint. If during the active growth of a puppy (the main growth of a large breed dog occurs in 4-8 months), damage to the growth zone of the radius occurs, this can lead to early post-traumatic closure of the metaphysis and the cessation of the formation of the radial bone in length, that is, its elongation. This in turn leads to a deformation of the articular surface of the elbow joint, when the humerus begins to touch and exert full pressure only on the articular surface of the ulna. This is clearly visible in the photo (shown by two arrows). Also, such uneven growth of the forearm bones may be associated with a breed predisposition or other unidentified reasons.

The humerus puts all the pressure on the ulna, which leads to destruction of the underlying tissues (cartilage and bone) and even fragmentation of areas of bone on the medial and lateral sides.

Symptoms of a shortened radius

Most cases occur in dogs under one year of age. The most susceptible breeds are: Bernese Mountain Dog, retrievers, mastiffs and other large dogs. The disease manifests itself as lameness in the affected forelimb. There may also be some pronation (rotation) of the forearm to reduce pain in the joint. Palpation can reveal swelling in the joint due to the accumulation of inflammatory synovium. The elbow joint is limited in movement (flexion-extension).

Diagnosis is quite simple. The radiograph shows shortening of the radius relative to the ulna. The radius extends beyond the joint (see below). CT can be used to diagnose secondary lesions such as fragmentation of the coronoid process at the elbow joint

Treatment is only surgical. It involves removing a segment of the ulna bone below the elbow joint. The amount of bone tissue that is removed is inversely proportional to the age of the dogs. In other words, if the dog is young (ie around 5 months), then a significantly wider segment must be removed from the ulna compared to a dog that is no longer growing (around 10 to 12 months). You can also wire the ends of the ulna to correct the relationship between the components of the elbow joint immediately after surgery. The space between the ends of the ulna heals over time, but this process can take up to 3 months if the defect is large. This operation, dynamic osteotomy of the ulna, is indicated for growing dogs.

A more complex form of treatment involves lengthening the radius itself, but this method is used for dogs that have stopped forming.

If necessary, fragmented areas can be removed arthroscopically or on an open joint, but this is not the primary therapy.

Preoperative radiograph shows a shortened radius and a joint defect of approximately 6 mm of discrepancy

X-ray before surgery in direct projection

An x-ray immediately after surgery shows the comparison of the components of the elbow joint, the formation of congruence. In this case, 1.5 cm of bone tissue was removed.

X-ray after surgery in direct projection

The invention relates to medicine and can be used in the treatment of injuries to the elbow joint. An L-shaped osteotomy of the olecranon is performed. First, an incomplete osteotomy of the olecranon is performed along the longitudinal axis in the sagittal plane to the middle of the olecranon. Channels are formed in the frontal plane for compression screws, and then the osteotomy is continued transversely outward. The method ensures restoration of joint function, reduction of trauma, elimination of postoperative complications, and reduction of treatment time. 8 ill.

The invention relates to medicine, namely to traumatology, and can be used in the treatment of injuries to the elbow joint.

There is a known method of osteotomy of the olecranon process for fractures of the distal part of the humerus (Guide to internal osteosynthesis, M. E. Muller, M. Allgover, et al., Ad Marginem, 1996, pp. 446-447), including a skin incision along the posterior surface of the shoulder, going around around the radial part of the olecranon along the crest of the ulna (posterior-external approach), performing a transverse or V-shaped osteotomy of the olecranon, reconstruction of the humerus and fixation of the osteotomized fragment with Kirschner wires or cancellous screws (Figure 1 shows a diagram of the V-shaped osteotomy olecranon).

The disadvantages of access are traumatic and risk of complications:

Transverse or V-shaped osteotomy leads to disruption of the musculoskeletal integrity of the elbow joint;

There is a possibility of damage to the radial nerve (N.ulnaris);

Isolation or abduction of the radial nerve (carried out if necessary) can lead in the late period after surgery, due to cicatricial adhesions, to late neuritis;

Removal of the fixators requires exposure of the posterior surface of the olecranon, which increases the morbidity.

In addition, the ends of the fixators (wires, screw heads) in the area of ​​the apex of the olecranon after the edema subsides cause discomfort in the patient in the postoperative period (during movement, contact with the surface, etc.).

The technical task - reducing the trauma of the operation, reducing the risk of complications, increasing the quality of life in the postoperative period - is solved as follows.

In the method of osteotomy of the olecranon, including posterior-external access, osteotomy of the olecranon with retraction of the fragment, reconstruction of the humerus and osteosynthesis of the fragment with fixators, according to the invention, an incomplete L-shaped osteotomy of the olecranon is performed: first, osteotomy of the olecranon is performed along the longitudinal axis in the sagittal plane to the middle of the olecranon, then transversely outward, while after performing a longitudinal osteotomy of the olecranon, channels are formed in the frontal plane for compression screws.

Performing an incomplete osteotomy of the olecranon process with an L-shaped section violates its musculoskeletal integrity to a lesser extent, preserving partial blood circulation, while there is no danger of damage to the ulnar nerve and the need to isolate it, which reduces the traumatic nature of the operation. The formation of channels for screws in the frontal plane after longitudinal osteotomy reduces the time of refixation of the osteotomized fragment of the olecranon, while the heads of the screws fixing the osteotomized fragment of the olecranon are in the frontal plane and do not cause discomfort in patients in the postoperative period; in addition, the fixators are removed through small incisions, which improves the cosmetic effect.

Thus, the use of the proposed method of olecranon osteotomy makes it possible to reduce the trauma of the operation, reduce the risk of complications, and also improve the patient’s quality of life in the postoperative period.

The method is carried out as follows. The patient is in a lying position on his stomach or on his healthy side. The arm is abducted, the shoulder lies on a stand fixed to the orthopedic table, the forearm hangs freely (bent at a right angle).

A skin incision is made along the back surface of the shoulder, bending slightly around the radial part of the olecranon, then along the crest of the ulna.

Using an oscillating saw, an incomplete L-shaped osteotomy of the olecranon is performed (along the longitudinal axis in the sagittal plane to the middle of the olecranon and transversely in the frontal plane outward). Before transverse osteotomy, 1-2 channels are formed through the longitudinal axis (vertical osteotomy line) in the frontal plane using a drill with a diameter of 2.5 mm for compression screws (diameter 3.5 mm) for subsequent refixation of the ulnar bone fragment. The length of the channels is measured and compression screws are selected in advance based on their length. The osteotomized fragment of the olecranon process, together with the external portion of the tendon of the 3rd head muscle of the shoulder, is retracted upward (cranially), exposing the posterior-inferior surface of the capitate eminence (head of the condyle) and the trochlea of ​​the humerus. The necessary reconstruction of the articular surface of the distal epiphysis of the humerus is carried out. Then the osteotomized fragment of the olecranon is refixed with pre-selected compression screws (Figure 2 shows a diagram of an incomplete L-shaped osteotomy of the olecranon).

Clinical example. Patient T., 26 years old. She was admitted a week after the injury with a diagnosis of a fracture of the head of the condyle and trochlea of ​​the left humerus, and a fracture of the head of the left radius. 10 days after the injury, surgical treatment was performed under general anesthesia: the patient was placed on her right side, the shoulder was fixed with a support. From the postero-external approach, the posterior surface of the elbow joint is exposed. The ulnar nerve was not identified. An incomplete, L-shaped osteotomy of the olecranon was performed. The osteotomized fragment is retracted upward (cranially), without violating the musculoskeletal integrity, opening a sufficient view of the humeroradial and glenohumeral joints. During the audit, it was revealed that the fragment (antero-inferior part of the head of the condyle and trochlea) measuring 3+1.5 cm was displaced anteriorly and upward. First, the fragment of the radial head was repositioned with a 3.5 mm lag screw. Using elevators, the articular fragment of the humerus was repositioned with two 3.5 mm lag screws. The osteotomized fragment of the olecranon is fixed with one 3.5 mm lag screw. The surgical wound is sutured in layers. Fixation with a scarf bandage. Movements in the damaged joint began on the 2nd day after surgery.

1 month after the operation the result is satisfactory. Figures 3-8 show radiographs of the patient in two projections (front and profile);

Fig.3, 4 - upon admission;

Fig.5, 6 - after surgery, the osteotomized fragment of the olecranon is fixed with one screw;

Figures 7, 8 - 1 month after surgery, signs of consolidation of the osteotomized fragment are visible.

There were no postoperative complications; in the postoperative period the patient did not experience discomfort during joint development and maintenance.

Thus, the proposed method of osteotomy of the olecranon process reduces the trauma of the operation, provides better conditions for blood supply to the restored tissues, reduces the risk of complications, improves the patient’s quality of life, which increases the effectiveness of treatment.

A method for osteotomy of the olecranon, including a postero-external approach, osteotomy of the olecranon with retraction of the fragment, reconstruction of the humerus and osteosynthesis of the fragment with fixators, characterized in that an L-shaped osteotomy of the olecranon is performed, while first an incomplete osteotomy of the olecranon is performed along the longitudinal axis in the sagittal plane to the middle of the olecranon, channels are formed in the frontal plane for compression screws, and then the osteotomy is continued transversely outward.

Possible treatment options

(Continued. Started in No. 3.2012)

Considering the proposed methods, for the treatment of end-stage MVO disease, we prefer subtotal osteotomy of the coronoid process (Fig. 2), in which the pyramidal part of the medial coronoid process, which forms the articular part distal to the level of the radial notch, is removed. Surgical intervention involves blunt separation of the flexor carpi radialis/pronator teres and flexor digitorum superficialis/deep muscles caudal to the medial collateral ligament to provide access, and then an incision through the medial surface of the joint capsule proximal to the fan-shaped attachment zone of the biceps brachii muscle on the medial aspect of the coronoid process. To facilitate access to the medial part of the joint, self-retaining retractors are used, which are secured caudal to the medial collateral ligament. We used a pneumatic pendulum saw for the osteotomy, 28 but similar effectiveness can be achieved using an osteotome or shaver.

The caudolateral boundary of the osteotomy was the junction of the radial notch and a point 1–2 mm distal to the sagittal edge of the ulnar notch. Microcracks of the subchondral bone extended to the border of this osteotomy line, 6 but the osteotomy zone included the entire area of ​​visible pathology of the cartilage and subchondral bone, determined histomorphometrically. 6 Our initial concerns about elbow instability (due to disruption of the ulnar collateral ligament) were not confirmed.

Subtotal osteotomy of the coronoid process in 263 dogs (437 elbows) achieved permanent and long-term (follow-up in some cases lasting 4-5 years) elimination of lameness with a low rate of complications after surgical treatment. 28 Other surgical methods for local treatment of MVO pathology include removal of loose fragments, varying degrees of clearance of destroyed material, curettage, or excision of a portion of the MVO with visible damage, by arthroscopy or arthrotomy. 4,14,17,40–44
Although histological findings suggest that this approach leaves a significant portion of damaged subchondral bone in place, 6 we are unaware of any clinical studies that clearly demonstrate the superiority of more aggressive arthroplasty (eg, subtotal coronoid osteotomy) over less aggressive approaches in regarding the outcome. A cohort comparative study is needed. If dynamic joint incongruence or abnormal dynamic loading are possible causes of MVO pathology, corrective osteotomy should probably be considered; however, without a good understanding of mechanics, it is unclear which osteotomy configuration will produce the best effect. In our experience, ulnar osteotomy results in lameness lasting several weeks. In addition, the severity of lameness is usually greater than before surgery or only after intra-articular intervention. This result would negate any possible benefit, at least in our experience; the long-term outcome is equivalent to that of dogs with MVO pathology without significant changes in the humeral condyle. However, if there is abrasion damage at the medial aspect of the humeral condyle or if there is obvious incongruity between the humerus and ulna as seen on CT or arthroscopy, ulnar osteotomy is warranted, as discussed below. We do not see the need for ulnar osteotomy unless the radius and ulna are clearly incongruent >4 mm.
To determine whether TSDM reduces contact pressure in ulnar-humeral discrepancies, it is necessary to know the biomechanical parameters. It remains to be seen whether TSDM can reverse disease progression, prevent cartilage damage or fragmentation of the MVO at the fracture site, or reduce persistent medial compartment abrasion after subtotal coronoid osteotomy due to friction. It is also unknown at this stage whether TSDM can be used for successful palliative treatment of the last stage of erosion of the medial compartment, when periarticular fibrosis or the depth of the pathology can neutralize the positive effect of tendon release. Conservative treatment remains the main alternative in cases where local surgery is not suitable or has already been performed but has not resulted in resolution of symptoms. Successful nonsurgical treatment plans include regular moderate exercise, weight control; prudent use of nonsteroidal anti-inflammatory drugs or prescription pain medications; the use of nutritional supplements or compounds that affect the course of the disease (for example, the most promising are preparations of glucosamine and chondroitin sulfate, or compounds such as pentosan polysulfate). Additional therapy, including limited strength training (eg, hydrotherapy), should also be considered; physiotherapy, such as massage; transcutaneous electrical nerve stimulation; shock wave therapy, holistic therapy, magnetic therapy or alternative therapy such as acupuncture. Although scientific evidence for the effectiveness of many of these methods is lacking, the large body of evidence for their use in other species and the low incidence of morbidity justify their use in selected cases.

Algorithm for choosing a treatment method for MVO lesions

According to our current algorithm (Fig. 4), subtotal osteotomy is indicated at the final stage of the process, when arthroscopy reveals changes such as fragmentation, large cracks, or sclerosis of the full thickness of the articular cartilage. If arthroscopy reveals early or mild MVO lesions, usually in the form of fibrocartilage formation at the surface or softening of the cartilage, which is often limited to the most craniomedial part of the coronoid process, other factors must be taken into account before deciding on subtotal osteotomy, TSDM or conservative treatment. .

These factors must be weighed by answering 3 questions:
1. Is subchondral bone pathology a significant enough cause of lameness or tenderness to justify subtotal osteotomy despite the absence of superficial pathology?
2. Do arthroscopic changes indicate possible rotational instability manifested by pathological changes in the area of ​​the radial notch, which justifies TSDM in an attempt to reduce the forces acting on the joint during supination?
3. Is the observed pathology likely to progress to the final stage of MVO lesions with lameness or pain if left untreated?

When deciding on subtotal osteotomy of the coronoid process in case of questionable results of arthroscopy, 2 factors are most important: the severity of clinical signs (lameness and pain during manipulation) and young age (when skeletal immaturity is considered a significant indicator of the subsequent development of the final stage of MVO lesion).

In addition, changes on the x-ray (including the subjective intensity of sclerosis at the trochlear notch), the ability of the owner and dog to comply with conservative treatment regimens, and the response to previous attempts at conservative treatment should be taken into account. For example, according to our algorithm, a 6-year-old dog with mild elbow lameness or tenderness and superficial localized fibrocartilage formation at the apex of the coronoid would be treated conservatively, while a 6-month-old dog with moderate lameness associated with superficial lesions of the medial aspect of the coronoid would receive mild treatment. severity, visible during arthroscopy, and intense sclerosis of tissues under the trochlear notch, visible on an x-ray, subtotal osteotomy of the coronoid process or TSDM is indicated, depending on the degree of pathology of the medial coronoid process (fiberization, cracks, fragmentation).
The sliding scale analogy is most useful when you need to consider these variables (Figure 5) in combination; in some cases there may be a slight degree of subjectivity. There is no doubt that ongoing research aimed at classifying and establishing the significance of MVO bone marrow lesions using MRI and CT will help eliminate this subjectivity. Comparison of changes seen on x-ray or arthroscopy with the results of micro-CT and histomorphometric analysis of excised coronoid fragments will also help clarify the relationship between incongruity and morphological changes and help develop future decision-making algorithms.

LESIONS TO THE MEDIAL CONDYLE OF THE HUMERUS

AC (and resulting ROC) is a well-known disease of the medial elbow that often occurs in association with MVO lesions (30/33 elbows in one of our studies 45 ). This may reflect the possible role of incongruity in the etiology and pathogenesis of both diseases, although multiple developmental factors play a role, including genetic factors 46 , 47 ; food 48; growth rate 49 and endocrine factors 50 . Many studies describe the treatment of these two diseases together, but they do not reflect the full spectrum of pathological changes found in our dog population. In particular, we frequently encountered MVO lesions in combination with varying degrees of cartilage erosion of the medial humeral condyle, apparently associated with MVO lesions, which further supports the role of incongruity in etiology and pathogenesis. These erosions are visible at arthroscopy or arthrotomy as clusters of linear areas of abrasion/streaks with an axial orientation, and the pattern can vary from superficial fission of the cartilage to full-thickness sclerosis with exposure of subchondral bone. In addition, the area of ​​the affected surface of the medial humeral condyle varies considerably, from limited areas of a few millimeters in diameter to erosion across almost the entire medial surface of the articular cartilage. These lesions are often located around or directly adjacent to the affected surface of the MVO, but remain clearly distinguishable both in appearance and in the depth of the subchondral bone defect. The pattern of cartilage damage in the medial aspect of the coronoid process is always similar within the same surface area (mirror image), while additional macroscopic fragmentation or fissure formation, although more common, is more variable.
With both surgical and conservative treatment of OCD of the medial humeral condyle (with or without MVO involvement), progression of osteoarthritis is inevitable, 3 but different outcome options within the spectrum of diagnosed disease, as well as detailed results in the medium and long term, are not described in most sources. . In our experience, the presence of significant cartilage damage to the medial humeral condyle is associated with relatively poor clinical outcomes and, in some cases, may continue to progress to full-thickness erosion of the medial aspect of the joint, even with concurrent treatment of MVO with subtotal osteotomy. In some cases, the relatively equal distribution of load between the large humerus-radius contact area and the small humerus-ulna contact area in the normal elbow joint contributes to the severity of the lesion 51 . It seems unlikely that the growth of fibrocartilage from the subchondral bone into this area (which is stimulated by bone threfination) will provide any significant or lasting protection to the subchondral bone plate, especially given its weight bearing, constant friction, and any possible dynamic incongruity. This outcome was confirmed by the results of repeated revision of arthroscopy results in a number of cases in which only fragment removal, curettage, treatment of cartilage microcracks or trefination were performed 24 . Thus, a number of treatments have been proposed for these problematic medial humeral condyle injuries, and the algorithm for selecting a technique has become relatively complex (Fig. 6) 34,52.

ROH

When ROC is detected in the absence of MVO lesions or erosion of the corresponding medial humeral condyle, the choice of treatment options is relatively simple. The pathology of MVO can be excluded mainly based on the results of arthroscopy (lack of softening of the cartilage, fiber disintegration, cracks and fragmentation). However, in cases where these end-stage manifestations of MVO lesions have not yet developed, despite significant pathology of the subchondral tissue, especially in young dogs, the results of radiography should also be taken into account, in particular the absence of abundant or intense sclerosis in the area under the trochlear notch or coronoid process 22 ,53. Traditional methods of surgical treatment (including curettage, microfractures, micropunctures) aimed at stimulating the growth of fibrocartilage are still considered justified for the treatment of small (maximum diameter<5 мм у собак средних и крупных размеров), мелких (дефект подхрящевой кости на глубину<1 мм) или абаксиальных поражений, когда прогноз, исходя из опыта, расценивается как относительно благоприятный. Опыт показывает, что при более значительных поражениях большего диаметра, с глубоким дефектом подхрящевой ткани или регенерацией с образованием волокнистого хряща такой метод недостаточен и не обеспечивает достаточной реконструкции контура сустава. Возможными причинами неблагоприятного клинического исхода считаются два аспекта: Во-первых, полагают, что по сравнению с гиалиновым хрящом, волокнистый хрящ с худшими механическими свойствами способствует снижению прочности в средне- и долговременной перспективе, что в конечном итоге приводит к склерозу, повторному обнажению подхрящевой кости и рецидиву хромоты.
Second, and perhaps more importantly, accurate restoration of the weight-bearing contour with fibrocartilage is unlikely, especially when there are significant defects in the subchondral bone plate. This may promote persistent tension around the residual defect, 54 resulting in cartilage abrasion, subchondral bone swelling, and damage to the opposing articular surface. As a result, although not proven in dogs, it may be a major cause of poor outcome, particularly because the elbow joint may involve a significant portion of the limited weight-bearing surface. Reconstruction of the joint contour is the primary goal of reconstructing osteochondral defects in humans, and a number of materials (autografts, foreign grafts, absorbable and nonabsorbable fillers) have been investigated for this purpose. Of the techniques available for practical use, the use of osteochondral autograft is the best suited for dogs. In this case, a cylindrical fragment is taken from the bone of the non-contact surface of the other joint of the dog, covered with intact cartilage (usually from the area of ​​the medial articular surface of the knee joint), which is implanted into the depression created at the site of the osteochondral defect (Fig. 7). This procedure accurately restores the contour of the joint and subchondral bone, and creates a durable surface of hyaline or hyaline-like cartilage. 45
By using polyurethane “cartilage substitute” plugs, graft removal from the donor site can be eliminated, operative time can be reduced, and the complexity associated with surface topographic mapping can be reduced.

(B) Arthroscopic image 12 weeks after surgery showing the healthy appearance of osteochondral autograft cartilage (right side of the image) used to treat an OCD lesion of the medial humeral condyle without associated MVO lesion. Photographs of the elbow joint of a Labrador retriever at the age of 3 years 8 months, who had previously undergone surgery to close the defect of the humeral condyle due to ROC with an autograft, in craniocaudal (C) and mediolateral (D) projections, without signs of progress of periarticular osteophytosis.

Such techniques are the subject of ongoing research, and mid-term (6-month) outcome measures based on clinical trial, arthroscopy, and MRI are encouraging. 55 Our clinical and arthroscopic results for 3 elbows diagnosed with MVO after autograft were excellent (Figure 7B), and follow-up of one dog for up to 3 years showed no progression of osteoarthritis (Figure 7C and D ). 45

ROH and the defeat of the MVO

ROH– the most common pathology, found in combination with MVO lesions in one joint. In this case, the treatment approach is based on the severity of the cartilage pathology, simultaneous damage to the coronoid process and the medial condyle of the humerus around or near the focus of RCD. When a MVO lesion is detected in combination with ROC of the medial condyle of the humerus, we consider subtotal osteotomy to be justified, regardless of the severity of the pathology on arthroscopy or radiography.
This approach is based on an understanding of the role of incongruence or point loading in the etiology and pathogenesis of both diseases, which can interfere with healing after treatment of OCD with any chosen method. We have not explored the possible significance of TSDM in this aspect. Subsequently, these doubts were confirmed by the insufficiently good results of treatment of 10 of 24 elbow joints with concomitant ROC and MVO lesions using subtotal osteotomy and autotransplantation. 45
After 12-18 weeks, arthroscopic exploration revealed progression of the cartilage pathology of the medial humeral condyle around the graft site (and the corresponding contact area of ​​the medial articular surface of the ulna proximal to the subtotal osteotomy site). In our opinion, this is caused by a discrepancy between the ulna and radius 39 ; Thus, in a subsequent series of joints with MVO and ROC lesions without additional erosions of the medial humeral condyle, we used a combination of autografting, subtotal osteotomy, and proximal osteotomy of the ulna. The outcome on clinical examination and arthroscopic exploration appears promising, and the inclusion of ulnar osteotomy in the treatment approach is likely responsible for this outcome. 45

Proximal osteotomy of the ulna. Although the optimal configuration, proximal-distal orientation, and need for intramedullary stabilization during ulnar osteotomy have not been established in the clinical setting, we believe a number of characteristics are important. Using an in vitro model of elbow joint incongruity, it was shown that distal osteotomy of the ulna does not restore congruency of the articular surface due to a strong interosseous ligament, while proximal osteotomy gives a better effect. 56
To prevent excessive inclination of the proximal segment of the ulna due to the pulling force of the biceps brachii muscle on the olecranon, to minimize the likelihood of delayed union after osteotomy, and to reduce excessive callus formation as a result of inevitable instability at the sites of transverse osteotomy, oblique osteotomy in the caudoproximal- craniodistal direction 2.
In vitro simulation of limb loading with oblique osteotomy without intramedullary fixation leads to varus deformity. If these effects are thought to be clinically insignificant, 57 prophylaxis with intramedullary stabilization has been suggested, 58 but is associated with some increase in complications (eg, pin breakage). 59 Therefore, we used an oblique configuration of the proximal ulnar osteotomy from caudoproximal to craniodistal (approximately 40° long axis) and proximolateral to distomedial (approximately 50° long axis). 45 The results of this technique of osteotomy without an intramedullary pin to correct radius-ulnar discrepancy and conditions such as olecranon nonunion (with a self-locking screw to secure the fragments) are promising, as they indicate reliable bone fusion without excessive callus formation and a positive clinical outcome . 60

Osteotomy is a surgical operation used in cases where it is necessary to eliminate a defect in bone tissue. Most often, the procedure is performed to restore bone after deformative damage.

Various segments can be operated on, including the bones of the legs and face. Osteotomy can only be performed in a hospital setting; it is not performed in clinics. Unfortunately, there is a risk of postoperative complications, especially if serious mistakes were made during the rehabilitation period.

The operation can be complex (when treating large leg bones, for example) or simple (mini-osteotomy). The risk of postoperative complications is higher in case of complex technique.

1 What is osteotomy: general description of the operation

Nowadays, almost any problem associated with deformative lesions of bones and joints can be solved without problems. It is to solve such problems that osteotomy is used.

The procedure is intended to eliminate bone defects and the consequences of tissue deformation. With the help of surgery, you can restore the functions of the musculoskeletal system, including through an artificial fracture.

A patient’s limb may be deliberately broken at the level where his deformity is localized. This technique is often used for congenital or acquired pathologies (for example, malunion of a fracture).

Due to its description and method of implementation, osteotomy can scare off most patients. In fact, everything is not as scary as it might seem: the patient does not feel anything during the operation (except perhaps moderate discomfort associated with the work of receptors that record mechanical stress).

The procedure has two types: through a small incision on the skin or by making several holes in the skin. This technique is used for both children and adult patients of different age groups.

1.1 What is it used for?

The procedure is applicable for the following groups of bones and joints:

• lower and upper jaw;
• pelvic bones, hip joints;
• shin bones, knee joint, metatarsal bone;
• elbow joints, bones of the upper extremities, including fingers and radius bones;
• it is possible to treat the femur (a rather complex procedure with risks of postoperative complications).

It is important to understand that each group of bones uses its own nuances of surgical intervention. In addition, different techniques can be used even for the same group of bones, but with different diseases.

For example, the femur can be treated using corrective and restorative osteotomy. The first option is suitable in cases where there is an incorrectly healed fracture. The second option is preferable for hip subluxation.

The final choice of technique remains with the attending physician. It is done after a series of diagnostic procedures.

1.2 Indications for testing

There are a fairly large number of indications for osteotomy, because in addition to general diseases (which can affect different joints and bones), there are also specific ones that arise only in a certain group.

Osteotomy is performed for the following pathologies:

1. Incorrectly healed fracture of one or another group of bones (in this case, it is possible to carry out an artificial fracture with subsequent normal healing of the bone).
2. Ankylosis of the joint in a vicious position.
3. Coxarthrosis
4. Valgus deformity.
5. Consequences of rickets in the form of curvature (deformation) of bones.
6. Traumatic deformative lesions.
7. Shortening or pathological lengthening of the bone.
8. Dislocations and subluxations of bones or joints.
9. Birth defects and structural abnormalities of certain bones.
10. Varus deformity.
11. False joint of the femoral neck.

The operation is often performed for various subtypes of arthritis (for example, psoriatic). The fact is that arthritis can lead to joint or bone deformities. As a rule, this happens only in the most advanced cases, when the disease lasts long enough.

The specificity of the procedure is the cure of deformative lesions as a result of injuries or complications of bones, but not joints. Treatment of complications of various types of arthritis is only an auxiliary function of osteotomy, which is not used constantly.

1.3 Contraindications

There are a fairly large number of contraindications to the procedure. They cannot be ignored, because in this case the situation can be aggravated, even to the point of disability.

Osteotomy cannot be performed in the following cases:

• during the period of acute onset or exacerbation of rheumatoid arthritis;
• third degree of patellofemoral subtype of arthrosis;
• obesity in a patient of 2-3 degrees (relative contraindication, in some cases ignored with the permission of the attending physician);
• presence of osteoporosis;
• violations of the regenerative functions of the body, in particular local ones (in terms of bone tissue regeneration);
• infectious pathologies of bone tissue (for example, syphilis or bone tuberculosis) - active or suffered in the recent past;
• arthrosis lesions (degenerative-dystrophic), localized in the collateral parts of the joints.

In addition, the operation cannot be performed if the patient has general weakness, exhaustion, cachexia, or fever (even with a minimally elevated temperature). Surgery is also prohibited if a clear diagnosis has not been established: for example, there are deformative bone lesions, but it is not known what caused them. First, a full diagnosis is made - then a decision is made to perform an operation.

2 Types of osteotomy

The operation has two types of conduct: closed and open method.

In a closed procedure, the operation is performed through a small (endoscopic) incision in the skin. The incision size usually does not exceed 2 centimeters. During a closed osteotomy, the doctor literally crosses the bones blindly using a special chisel. This is a difficult and dangerous technique, since incorrect actions by a specialist can lead to a number of serious complications.

Open osteotomy is used much more often, including due to lower risks of serious complications. Here the doctor is no longer working blindly: there is the possibility of full visualization of the operated tissues. The incision on the skin for this technique is much larger and is up to 12 centimeters in length.

Osteotomy is also divided into several subtypes:

1. Linear subtype (transverse or oblique). The diseased bone is cut in such a way that it is then smoothed using a graft (plates). In dental implantology, intercortical osteotomy is performed to eliminate jaw defects.
2. Wedge-shaped subtype (akin, Akin). During the procedure, part of the bone tissue is removed from the patient, due to which the remaining intact bone is subsequently aligned.
3. Z-shaped subtype. Used to treat hallux valgus. During the procedure, the doctor removes overgrown tissue.
4. Angular subtype. Bone tissues are carefully cut at certain angles on both sides, due to which it is possible to place them in the required position.

3 How is the operation performed?

There is no universal method for performing osteotomy: each case (disease) uses its own technique.

For example, during corrective surgery on the pelvic bones, the ilium is cut in the area above the acetabulum. Next, the pelvic joint is displaced to create an artificial “shield” over the articular head. The procedure is performed under endotracheal anesthesia (the safest option in this case).

Surgery of the knee joints is usually performed to treat deforming arthrosis. The tibia is transected, which leads to improved metabolism in the joint tissue by eliminating stagnation of venous circulation.

The feet are usually treated for hallux valgus. To do this, the doctor makes an incision at the end of the bone adjacent to the big toe and then places it closer to the inside of the foot. As a result, it is possible to eliminate the displacement, but sometimes it is necessary to remove part of the overgrown bone tissue.

Sometimes doctors use some tricks when operating on non-specific cases of diseases. That is, right during the operation, the standard tactics of action may change. As a rule, this only has a better effect on the patient’s recovery.

Whatever specific procedure is performed, there is always a non-zero chance of complications after the operation. Often complications are caused by improperly carried out rehabilitation stage.

3.1 Where is it carried out and how much does it cost?

Such complex surgical procedures are performed only in large public hospitals or private clinics. It is advisable to contact specialized medical centers that deal exclusively with diseases of the musculoskeletal system.

The cost depends on the type of surgery. For example, a corrective osteotomy costs around 50,000 rubles. The average cost of the procedure, regardless of its type, ranges from 60-65 thousand rubles.

3.2 Dressing after osteotomy (video)

3.3 Rehabilitation after osteotomy

Restoring the function of the operated bone is at least 50% of the success of the entire treatment.

It is important to understand that in most cases, the bone will no longer be functionally the same as it was before the disease and surgery. However, it is possible that the functionality will be restored in such a way that there will not be much difference (in terms of sensations).

How exactly rehabilitation should be carried out after an osteotomy depends on which method of operation was performed and on what area.

There are general rules:

1. For the first time after the procedure, complete rest of the area that was operated on is required. There should not be any load, even minimal.
2. Later, the patient is prescribed minimal physical activity to restore bone functionality. A dosed load triggers the acceleration of regeneration of operated tissues. The decision about when and how to load the operated part of the body should be made only by the attending physician.
3. Medical corsets, orthopedic insoles and other tools can be used to reduce the load on the bones.
4. Medications (anti-inflammatory, regenerative) must be prescribed. Painkillers and muscle relaxants may be used as needed.

Recovery from an osteotomy may take several months. It is very important to follow all the doctor’s instructions: improper rehabilitation can not only ruin the effect of treatment, but also make it worse than it was before the operation.

Elbow dysplasia in dogs is a polygenically inherited disease that leads to a pathological structure of the joint, improper articulation of the head of the humerus and the sockets of the radial bones. Due to the incorrect structure, the joint quickly wears out, and progressive arthrosis occurs.

The elbow joint is created on one side by the ginglim-shaped head of the humerus, and on the other side by the articular cavity of the radius and the lunate notch of the ulna. The shape of the joint allows only bending along the body, but at the same time creates a high range of motion - up to 120o.

The semilunar notch fixes the head of the humerus and is a guiding block for flexion and extension. On the ulna you can see the uncinate process, which gives the glenoid cavity a crescent shape and also limits movement when extending the limb.

Please note right away that there is no diagnosis of “dysplasia”. Dysplasia is a collective name for several similar pathologies.

The term itself refers to the abnormal development of bones, organs, tissues and body parts. This is a general definition of all anatomical pathologies that form in the embryonic and postnatal period.

Elbow dysplasia includes 4 types of pathologies:

• Fragmentation of the olecranon process, that is, its separation from the ulna.
• Chipping of the coronoid process.
• Disconnection of the uncinate process
• Osteochondritis dissecans.
• Mechanical discrepancy between the bones of the joint (discongruence).

As a result, it develops arthrosis and lameness, the symptoms for all pathologies are identical, so they can only be distinguished on an x-ray.

Causes of pathology

Dysplasia is caused by irregular and uneven growth of the bones of the elbow joint. As a result, the depth or shape of the glenoid fossa changes, which is why the head of the humerus does not fit into the socket and oscillates in it. The head may fit tightly into the articular fossa, but the load is distributed unevenly. Because of this, the cartilage of the joint begins to wear out, and arthrosis develops.

The main reason is genetic abnormalities. A predisposition to the disease has been identified in some breeds of dogs, mainly in large pets with large body weight.

It has been noted that dogs up to 25 kg never suffer from dysplasia, since the development and growth of their musculoskeletal system is uniform, without sudden jumps.

Pathology of the structure begins to be observed between 4 and 5 months of age, at this time the pet’s growth reaches its peak, the first, while minor, symptoms are visible from 4 to 8 months of the dog’s life. Due to the uneven development of the bones of the elbow, its normal structure is disrupted, which leads to overload in certain places of the joint and arthrosis.

Thus, there is no direct genetic predisposition, but large height and weight in itself is a predisposing factor. The second factor in the development of dysplasia is an unbalanced diet in the period from 4 to 5 months, due to which the bones of the elbow joint grow unevenly.

It is worth noting that often an additional factor in the development of the disease is an excess of calcium, phosphorus or vitamin D in the diet, which owners, oddly enough, introduce into the menu precisely to avoid the development of dysplasia. Thus, it is not the lack of these elements that increases the risk of developing pathology, but an overall unbalanced diet.

Symptoms of dysplasia

The first sign is lameness – appears between 1-2 years. The animal cannot run; lameness may be on both front legs or only one. The muscles of the diseased limb gradually atrophy. Due to the increased load on a healthy paw, arthrosis can also develop in it. An x-ray is sufficient to make a diagnosis.

Lameness can be detected between 4-10 months, but more often owners notice symptoms at 10-12 months of a pet’s life.

Lameness should be suspected when:

• the dog refuses to follow the command “give me your paw”, although it used to do it easily;
• whines when trying to examine and feel the elbow joint;
• the pet is afraid to go down the stairs, does it sideways, or simply refuses to go down;
• The dog stopped running, although it used to play active games with pleasure.

Signs are also visible when palpating the joint:

• crepitus is heard during passive flexion and extension of the joint, and the dog becomes anxious due to pain;
• thickening of the joint and bones in it is detected;
• effusion is felt in the joint with lateral eversion;
• in severe cases, the joint even looks abnormal in appearance;
• muscles may become tight.

It should be remembered that dysplasia usually develops on both front legs at once. The disease can be asymptomatic in the presence of minor disorders, for example, with fragmentation of the internal coronoid process. Symptoms intensify after active games, long walks, and training.

Painful sensations are not caused by dysplasia, but osteoarthritis, therefore, the extent of the pathological process depends on the condition of the cartilage:

• First degree(sometimes called zero) – the presence of dysplasia in the complete absence of pathologies in the structure of cartilage.
• Second degree(sometimes called borderline) - on x-ray you can find areas of compaction - sclerosis. The animal feels well, but after increased exercise there is slight lameness.
• T third degree(in some sources the first) – individual osteophytes no larger than 2 mm in size are found. The dog limps constantly and behaves restlessly when the joint is palpated.
• Fourth degree(in some sources the second) - osteophytes ranging in size from 2 to 5 mm are visible in the picture. The dog cannot move the affected limb and experiences severe pain with passive movement.
• Fifth degree(sometimes called the third) – osteophytes larger than 5 mm are recorded. The pet is unable to move its paw; often this cannot be achieved even through passive movement during anesthesia, since large osteophytes block the movement of the bones of the joint.

Diagnosis of dysplasia

Both front paws are examined on x-rays, as dysplasia usually develops in both limbs. Typically, dysplasia is not difficult to diagnose:

• The mediolateral view is suitable for diagnosing fragmentation of the uncinate or olecranon process.
• To diagnose osteochondritis dissecans, a craniocaudal oblique projection is needed.
• To establish the incongruity of the joint bones, the craniocaudal and mediolateral projections are most suitable.

It is much more difficult to detect fragmentation of the coronoid process. For this, a craniocaudal projection is used, but even with such an image, the severed coronoid process is not always visible; it can only be detected with a high-quality image. Therefore, in the absence of other forms of dysplasia and in the presence of secondary signs (osteophytes, cartilage sclerosis), fragmentation of the coronoid process is diagnosed.

When diagnosing, it is important to assess the general condition of the joint, which is not always possible to do using x-rays, so macroscopic and microscopic examinations are performed examination of joint synovial fluid.

Norma is a straw-yellow liquid of normal viscosity, with no more than 3000 cells per microliter, of which 90% are band cells. With fragmentation of various processes, as well as with arthrosis, the number of cells increases to 10,000 per microliter, the synovial fluid becomes viscous, with impurities of fibrin, and sometimes blood.

Treatment of the disease

Effective treatment without surgery is impossible; conservative methods give results only in every third case and only with fragmentation of the coronoid process. Other types of dysplasia require surgery.

Symptomatic therapy

To slow down the development of osteoarthritis and pain relief, the following methods are used:

• The dog is prescribed a diet to reduce body weight, this reduces the load on the joint.
• Chondroprotective drugs are prescribed, but they are effective only in the second degree of osteoarthritis and partially in the third.
• Intra-articular injections of hyaluronidase are prescribed.
• Analgesics and non-steroidal anti-inflammatory drugs are used for pain relief, but their effect is twofold, as the dog will increase the load on the joint, which will accelerate degeneration.
• Physiotherapy procedures are used: electrophoresis, electrical stimulation, hydrotherapy and others.

Corticosteroids should not be prescribed due to their negative effects on the structure of cartilage.

Surgical treatment

Depending on the exact diagnosis, surgical treatment of elbow dysplasia may consist of various procedures:

• Fragmentation of the olecranon process. Initially, they try to secure it with a screw; unfortunately, this method is often ineffective; in this case, the olecranon process is simply removed.
• Fragmentation of the coronoid process. It is simply removed, this is enough for the disease to stop progressing.
• Fragmentation of the uncinate process. Usually the uncinate process is removed, since its reattachment with a screw is almost impossible.
• Osteochondritis dissecans. First, all fragments are removed from the joint cavity, abrasion is carried out if necessary, then a course of chondrostimulation is prescribed to restore cartilage tissue.
• Discongruence of joint bones. It is often not treated due to the complexity of the operation. But with some experience of the surgeon, he can perform reconstructive surgery or resort to other methods (arthroscopy, dynamic osteotomy). Their goal is to change the direction of load in the joint.

What to do and what surgery to prescribe is decided by the doctor based on an accurate diagnosis. But owners need to remember that surgical treatment is not capable of restoring articular cartilage; it only eliminates the cause of osteoarthritis. Therefore, after surgery, a course of rehabilitation therapy is necessary.

Prevention of dysplasia

Since the disease is inherited, the best method of prevention is to exclude dogs with dysplasia from breeding work. Unfortunately, this method is not effective enough, since the reason is not the presence of genes itself, but the large height and body weight of some breeds.

Treatment is most effective when dysplasia is detected early, so it is advisable to x-ray large breed dogs at 5-6 months for signs of dysplasia, regardless of symptoms.