Interview Questions for Osteotomies

Osteotomies are surgical procedures involving cutting a bone to correct deformities, realign joints, or improve bone healing. They are classified in various ways, but common categorizations include:

• Based on the type of cut: This can include transverse, oblique, wedge, or step-cut osteotomies. A transverse osteotomy is a straight cut across the bone, while an oblique osteotomy is an angled cut. Wedge osteotomies remove a wedge-shaped piece of bone, changing the bone’s length and alignment. Step-cut osteotomies create a stair-step pattern.
• Based on the bone involved: Osteotomies can be performed on any bone in the body, with common examples including femoral osteotomies (thigh bone), tibial osteotomies (shin bone), and distal radius osteotomies (forearm bone).
• Based on the corrective action: These include valgus (lateral opening), varus (medial opening), and rotational osteotomies.

The choice of osteotomy type depends entirely on the specific deformity being corrected and the surgeon’s preferences.

A valgus osteotomy involves creating a lateral opening in a bone. This procedure is indicated for several conditions, primarily when a bone is angled too far medially (towards the midline of the body), leading to joint stress or pain.

• Knee osteoarthritis: In cases of medial compartment osteoarthritis of the knee, a valgus osteotomy can unload the affected compartment by shifting weight laterally.
• Femoral neck fractures: In some cases of femoral neck fractures, a valgus osteotomy might be used to improve the biomechanics and stability of the repaired fracture.
• Leg length discrepancy: A valgus osteotomy can be used in conjunction with other procedures to address leg length discrepancies.
• Tibial varus deformity: A valgus osteotomy of the tibia can correct a bow-legged deformity.

Essentially, a valgus osteotomy aims to redistribute weight across a joint, reducing the pressure on the damaged area and promoting more even weight distribution.

Contraindications for corrective osteotomies are situations where the procedure is likely to be ineffective or could cause more harm than good.

• Severe osteoporosis: Weak bones are at high risk of fracture or non-union (failure to heal properly).
• Inadequate bone stock: Insufficient healthy bone may prevent proper healing or stable fixation.
• Infection: Active infection near the surgical site significantly increases the risk of complications.
• Poor patient compliance: Patients who fail to follow post-operative instructions (e.g., weight-bearing restrictions) are at higher risk of complications.
• Severe vascular insufficiency: Compromised blood supply to the bone impairs healing.
• Severe neurological deficits: Pre-existing nerve damage may be exacerbated.
• Unrealistic patient expectations: Clear communication of realistic outcomes is crucial; unrealistic expectations can lead to dissatisfaction.

A thorough pre-operative assessment is essential to identify these contraindications and avoid unnecessary risks.

Distal femoral osteotomies are performed near the lower end of the femur. The specific technique varies depending on the desired correction (valgus, varus, rotational). A common approach involves:

1. Skin incision: A medial or lateral incision is made depending on the type of osteotomy required.
2. Exposure of the distal femur: The soft tissues are carefully dissected to expose the distal femoral metaphysis.
3. Osteotomy creation: Precise osteotomies are made using an osteotome, saw, or specialized instruments, based on pre-operative planning and imaging.
4. Bone preparation: The bone fragments are carefully prepared for fixation.
5. Fixation: Internal fixation typically uses plates and screws, sometimes locking plates for enhanced stability. External fixation may be used in certain circumstances.
6. Wound closure: The incision is meticulously closed in layers, followed by a sterile dressing.

The use of intraoperative imaging (fluoroscopy) is essential to ensure precise osteotomy placement and accurate fixation. Postoperative imaging confirms the success of the procedure.

Selecting the appropriate osteotomy technique involves a multi-faceted decision-making process, considering several factors:

• The nature and severity of the deformity: The type of osteotomy (e.g., valgus, varus, rotational) is dictated by the specific deformity.
• The patient’s age, bone quality, and overall health: Osteoporotic bone may require different fixation techniques than healthy bone. The patient’s general health influences tolerance to surgery and recovery.
• The patient’s activity level and functional goals: High-demand patients might benefit from more stable fixation methods.
• Imaging studies: Pre-operative radiographs, CT scans, or MRI scans provide detailed information on the bone anatomy and the extent of the deformity.
• Surgeon’s experience and expertise: The surgeon’s experience with various osteotomy techniques influences their choice.

Often, a combination of factors determines the most appropriate technique. For example, a patient with moderate medial compartment knee osteoarthritis and good bone quality might be suitable for a medial closing wedge osteotomy of the distal femur. On the other hand, a patient with severe osteoporosis might necessitate a different approach, perhaps using less invasive techniques or alternative treatments.

Postoperative care for an osteotomy is crucial for successful healing and optimal outcome. It typically involves:

• Pain management: Analgesics are used to manage pain.
• Wound care: The incision site is monitored for signs of infection.
• Early mobilization: Gradual weight-bearing as tolerated and physical therapy are typically initiated to restore range of motion and strength.
• Protection from stress: This may involve bracing, crutches, or other assistive devices to reduce stress on the healing bone.
• Regular follow-up appointments: These visits allow monitoring of healing progress, detection of potential complications, and adjustments to the rehabilitation plan.
• Weight-bearing restrictions: Specific weight-bearing restrictions are prescribed based on the type of osteotomy and fixation method.

The duration of post-operative care varies based on the complexity of the osteotomy, the patient’s healing rate and overall health, and compliance with the rehabilitation program.

Potential complications of osteotomies, while relatively uncommon with proper surgical technique and post-operative care, can be serious. These include:

• Non-union: Failure of the bone to heal.
• Malunion: Healing in an incorrect position.
• Infection: Infection at the surgical site.
• Hardware failure: Problems with the plates, screws, or other implants.
• Nerve or vascular injury: Damage to nearby nerves or blood vessels.
• Delayed union: Slower than expected healing.
• Osteonecrosis (avascular necrosis): Death of bone tissue due to insufficient blood supply.
• Deep vein thrombosis (DVT): Formation of a blood clot in a deep vein.
• Compartment syndrome: Increased pressure within a muscle compartment compromising blood supply.

Careful surgical planning, meticulous surgical technique, and diligent post-operative management are crucial in minimizing the risk of complications.

Postoperative pain management after an osteotomy is crucial for patient comfort and successful recovery. It’s a multi-modal approach, combining pharmacological and non-pharmacological methods.

Pharmacological management typically involves a combination of analgesics. This might start with strong opioids in the immediate postoperative period, gradually transitioning to weaker opioids and non-opioid analgesics like NSAIDs (nonsteroidal anti-inflammatory drugs) as pain subsides. Regular pain assessments are essential to adjust medication accordingly. We often employ patient-controlled analgesia (PCA) pumps to empower patients in managing their pain.

Non-pharmacological methods are equally important. These include ice packs to reduce swelling and inflammation, elevation of the limb to minimize edema, and physical therapy to improve range of motion and strength. Early mobilization, as tolerated, is encouraged to prevent stiffness and promote healing. Nerve blocks can be used pre- or post-operatively to reduce pain significantly.

For example, in a tibial osteotomy for correction of a varus deformity, a combination of PCA with morphine, followed by oxycodone and ibuprofen, along with regular ice packs and physiotherapy, would be a typical pain management strategy.

Proper fracture healing in osteotomy cases is paramount because the success of the procedure hinges on it. An osteotomy, by definition, involves creating a controlled fracture to reshape or realign a bone. If the bone doesn’t heal correctly, the procedure fails, potentially leading to complications like malunion (incorrect healing), nonunion (failure to heal), or delayed union (slow healing). This can result in persistent pain, instability, deformity, and the need for revision surgery.

Factors influencing fracture healing include adequate blood supply to the bone fragments, proper alignment and stability of the osteotomy site, the patient’s overall health (e.g., presence of comorbidities like diabetes or smoking), and the type of fixation used. We aim for stable fixation to minimize movement at the fracture site, promoting optimal healing conditions. Careful surgical technique and meticulous postoperative care are also crucial for successful bone healing.

Imagine a situation where a patient undergoes a femoral osteotomy for a correction of a leg length discrepancy. If nonunion occurs, the patient will have persistent pain and instability, potentially requiring bone grafting or other complex revision procedures. This highlights the importance of ensuring proper healing.

Several imaging modalities are employed to assess osteotomy healing. The choice of modality depends on the stage of healing and the specific clinical question being addressed.

• X-rays: These are the most commonly used initial imaging modality. They provide a good overall assessment of bone alignment, callus formation (the new bone that forms at the fracture site), and the presence of any signs of nonunion or malunion. Serial X-rays are routinely obtained to monitor healing progress.
• Computed Tomography (CT) scans: CT scans offer higher resolution than X-rays, allowing for a more detailed evaluation of bone architecture and fracture healing. They are particularly useful for assessing complex osteotomies or when there is a concern about subtle malalignment.
• Magnetic Resonance Imaging (MRI): MRI provides excellent soft tissue visualization. It is particularly helpful in evaluating the presence of edema (swelling), inflammation, and the quality of bone marrow in the healing fracture site. MRI can help differentiate between different types of delayed healing.

For example, early in the healing process, serial X-rays might reveal progressive callus formation. If there is a suspicion of nonunion despite clinical healing, an MRI might reveal persistent edema or insufficient bone marrow activity in the fracture site, guiding further management decisions.

Internal fixation plays a vital role in osteotomies by providing stability to the bone fragments, allowing for optimal healing. It minimizes movement at the osteotomy site, promoting bone union and reducing the risk of complications like malunion or nonunion. The choice of internal fixation depends on several factors, including the location and type of osteotomy, bone quality, and patient-specific factors.

Internal fixation not only improves the chances of successful healing but also allows for earlier weight-bearing and mobilization, speeding up patient recovery. Without stable internal fixation, the osteotomy site would be prone to movement, potentially disrupting the healing process and delaying rehabilitation. Furthermore, it ensures the precise alignment and correction of the bone achieved during the osteotomy procedure are maintained throughout the healing process.

For instance, in a corrective osteotomy of the tibia, stable internal fixation with a plate and screws allows for early weight-bearing and reduces the risk of deformity recurrence. This contrasts with situations where less stable fixation is used, potentially necessitating prolonged non-weight bearing and a higher risk of complications.

A variety of fixation devices are used in osteotomies, each with its advantages and disadvantages. The choice depends heavily on the specific osteotomy being performed.

• Plates and screws: These are widely used for their strength and versatility. Plates provide rigid fixation, while screws provide compression at the fracture site. Different types of plates exist, including locking plates which offer enhanced stability.
• Intramedullary nails: These are long rods inserted into the medullary canal (the hollow center) of the bone. They provide axial stability and are particularly useful for long bones.
• Screws alone: In some situations, screws alone may suffice for fixation, particularly in smaller bones or when the osteotomy is minimally displaced.
• External fixators: These are external devices that provide stability to the bone fragments. They are useful in cases where internal fixation is not feasible or desirable.

The selection of the fixation method is often a surgical decision based on the fracture characteristics and patient-specific factors. A surgeon might opt for a plate and screws for a complex tibial osteotomy to provide rigid fixation and compression, whereas an intramedullary nail might be preferable for a femoral osteotomy.

Assessing the stability of an osteotomy after surgery is critical to ensure successful healing. It involves a combination of clinical examination and imaging.

Clinical examination includes evaluating the presence of any pain, swelling, or tenderness at the osteotomy site. Assessing the patient’s range of motion and ability to bear weight are also important. Instability may manifest as increased pain on weight-bearing or palpable movement at the fracture site.

Imaging assessment, primarily X-rays, plays a crucial role. We look for the appropriate alignment of bone fragments, ensuring there’s no significant displacement or angulation. The quality of bone apposition (the contact between bone fragments) and presence of any signs of early callus formation are also evaluated. If there’s a concern about stability, a CT scan might provide a more detailed assessment.

For example, in a patient who has undergone a high tibial osteotomy, post-operative X-rays would confirm the correct varus/valgus correction and any signs of implant failure or displacement. If there is persistent pain or instability on weight-bearing, further investigations, such as a CT scan, may be necessary.

Pre-operative planning for an osteotomy is crucial for surgical success. It involves meticulous analysis of pre-operative imaging, typically X-rays and/or CT scans, to determine the optimal surgical approach and osteotomy site.

The process usually begins with a detailed assessment of the anatomical deformity, measuring the angles and dimensions of the bone involved. This is often done using specialized software that allows for three-dimensional (3D) reconstruction of the bone from the imaging data. The surgeon then uses this information to plan the exact location and orientation of the osteotomy, as well as the degree of correction required. This allows them to determine the size and type of fixation devices needed. Templates or guides might be generated from the 3D model for use intraoperatively.

This meticulous planning helps minimize intraoperative time, reduces complications, and increases the chances of achieving the desired clinical outcome. For example, in a case of a tibial osteotomy for correction of a varus deformity, precise pre-operative planning, using CT scans and specialized software, ensures accurate measurement of the varus angle and the precise location for the osteotomy cut, leading to a successful correction.

Computer-assisted surgery (CAS) has revolutionized osteotomies, enhancing precision and accuracy. It uses 3D imaging (CT scans or intraoperative fluoroscopy) to create a virtual model of the bone, allowing surgeons to plan the osteotomy precisely before making any incisions. This pre-operative planning minimizes errors and reduces the risk of complications.

During the surgery, CAS systems provide real-time guidance, ensuring the osteotomy is performed exactly as planned. This is particularly crucial in complex osteotomies, such as those involving the pelvis or distal tibia, where precise bone cuts are essential for optimal results. For instance, in a high tibial osteotomy for osteoarthritis, CAS helps ensure the correct amount of correction is achieved, improving alignment and reducing stress on the joint. Think of it like having a GPS for surgery, guiding the surgeon to the exact location for the bone cut.

Benefits of CAS include improved accuracy, reduced operative time, less blood loss, decreased risk of nerve or vessel injury, and potentially better functional outcomes. However, it’s important to note that CAS requires specialized training and equipment, which might not be readily available in all surgical settings.

Bone grafting in osteotomies is crucial for achieving solid bone union after the osteotomy has been performed. The principles revolve around providing a scaffold for new bone formation and stimulating the healing process. The graft acts as a bridge, filling the gap created by the bone cut. This is especially vital in situations where there is a significant bone defect or where bone healing is expected to be challenging.

Several types of bone grafts exist, including autografts (taken from the patient’s own body), allografts (from a donor), and synthetic grafts. Autografts are considered the gold standard due to their osteoinductive and osteoconductive properties – meaning they stimulate new bone formation and provide a framework for bone growth. However, they require a second surgical site for harvest. Allografts and synthetic grafts offer alternatives, but they may have limitations in terms of their osteoinductive potential. The choice of graft depends on factors such as the size of the defect, the patient’s overall health, and the surgeon’s preference.

Successful bone grafting requires proper graft placement, adequate fixation of the osteotomy fragments, and meticulous surgical technique to minimize infection and ensure optimal blood supply to the graft site. Post-operative monitoring is crucial to ensure proper healing.

Nonunion, the failure of a fracture or osteotomy to heal, and malunion, healing in a malaligned position, are serious complications after osteotomy. Management strategies vary depending on the severity and the time elapsed since the procedure.

Treatment options for nonunion may include:

• Surgical revision: This involves removing the non-union site, grafting bone, and potentially adding additional fixation.
• Electrical stimulation: This helps stimulate bone growth.
• Bone growth factors: These substances can be applied to promote healing.

Malunion is often addressed surgically with an osteotomy to correct the alignment followed by bone grafting and fixation. The specific surgical approach depends on the degree of malalignment and the bone involved. Non-operative management, such as bracing or physical therapy, is less effective for significant malunions.

Early diagnosis and prompt intervention are key to improving outcomes. Regular clinical and radiographic monitoring are critical in identifying these complications early.

Osteotomy healing is a complex process influenced by various factors. These can be broadly categorized into patient-related, surgical technique-related, and implant-related factors.

Patient-related factors: Age, general health (e.g., diabetes, smoking), nutritional status (vitamin D and calcium levels), and the presence of underlying diseases affect bone healing capacity.

Surgical technique-related factors: Adequate reduction (alignment of bone fragments), stable fixation, meticulous soft tissue handling, avoidance of infection, and proper bone grafting all play crucial roles. A poorly performed osteotomy with inadequate reduction and fixation is far less likely to heal properly.

Implant-related factors: Implant choice, stability of fixation, and the biocompatibility of the implant all impact bone healing. Inappropriate implant selection or poor surgical technique in placement can significantly hinder healing.

Understanding and optimizing these factors is essential for maximizing the chances of successful osteotomy healing.

Physiotherapy plays a vital role in osteotomy rehabilitation, aiming to restore joint mobility, strength, and function. The specific exercises and treatment plan depend on the type of osteotomy and the patient’s overall health.

Early stages focus on pain management, reducing swelling, and improving range of motion through gentle exercises. Protecting the surgical site and preventing stiffness are crucial.

Later stages emphasize strengthening exercises to improve muscle strength and stability around the joint. This is critical for returning to functional activities. Proprioceptive exercises, which improve balance and coordination, are also essential.

Functional rehabilitation focuses on activities of daily living and return to work or sports. The physiotherapist will guide the patient through a gradual increase in activity levels, ensuring they don’t overexert themselves.

A tailored physiotherapy program, developed in collaboration with the surgeon, significantly contributes to a successful outcome and helps patients achieve their functional goals.

Internal fixation, the use of implants to stabilize bone fragments after an osteotomy, carries potential complications. These include:

• Infection: A serious complication that can lead to implant failure and nonunion. Meticulous surgical technique and antibiotic prophylaxis help minimize this risk.
• Implant failure: Fracture or loosening of the implant, requiring revision surgery. This can be due to inadequate fixation, stress shielding (where the implant bears too much stress, inhibiting bone healing), or poor bone quality.
• Nerve or vessel injury: Can occur during surgery, leading to neurological deficits or vascular compromise. Careful surgical planning and execution help avoid this.
• Malunion or nonunion: As previously discussed, these complications necessitate further intervention.
• Hardware irritation or prominence: The implant may cause irritation or discomfort to the surrounding tissues.

Careful patient selection, meticulous surgical technique, and appropriate implant choice minimize these risks. Post-operative monitoring is essential for early detection and management of any complications.

Selecting the appropriate implant for an osteotomy depends on several factors including the type of osteotomy, the bone involved, the patient’s bone quality, and the desired level of stability. There’s no one-size-fits-all answer.

Considerations include:

• Bone quality: Osteoporotic bone requires implants that distribute stress effectively to avoid fracture.
• Type of osteotomy: A simple osteotomy may only require screws or plates, while complex osteotomies might need more advanced constructs like locking plates or intramedullary nails.
• Biocompatibility: The implant should be biocompatible to minimize adverse tissue reactions.
• Surgical access: The size and shape of the implant should allow for easy insertion and placement.

For example, a simple wedge osteotomy of the distal femur might be adequately fixed with screws, while a complex corrective osteotomy of the proximal tibia might require a locking plate for improved stability. The surgeon carefully weighs these factors to select the implant that provides optimal stability and allows for appropriate bone healing.

Stress shielding in osteotomies refers to the phenomenon where a bone segment, after an osteotomy and the subsequent implantation of a metal implant (like a plate and screws), experiences a reduction in its natural mechanical loading. The implant, being stronger than the bone, bears the majority of the stress, effectively shielding the bone from its normal physiological loading. This lack of stress can lead to bone resorption (loss of bone mass) in the area around the implant, weakening the bone over time and potentially leading to implant failure or fracture.

Imagine a strong metal brace supporting a weak wooden beam. The brace takes most of the weight, leaving the beam relatively unloaded. This is analogous to stress shielding. The bone, not being stressed, starts to weaken, much like the under-supported wooden beam.

Minimizing stress shielding is crucial. Techniques like using less rigid implants, employing bone grafting, and optimizing implant placement can help to distribute the load more evenly and encourage bone healing.

The biomechanical principles behind osteotomies are complex and multifaceted. They involve understanding the bone’s mechanical properties (strength, stiffness, elasticity), the forces acting on it, and the effect of the osteotomy itself. The primary goal is to precisely alter the bone’s geometry to correct a deformity or improve its alignment, restoring normal biomechanics.

• Load Distribution: Osteotomies aim to redistribute loads to prevent overload on one part of the bone, or to better support the joint.
• Strain: Bone remodeling depends on the strain it experiences. Carefully planned osteotomies manipulate the strain distribution to stimulate bone healing and prevent weakening.
• Joint Mechanics: Osteotomies often impact joint loading and motion. Precise cuts and corrections are essential to restore or improve joint function.
• Stability: Appropriate fixation methods (plates, screws, external fixators) are crucial to maintain stability post-osteotomy, facilitating bone healing and preventing complications.

For example, in a high tibial osteotomy for osteoarthritis, the aim is to shift the weight-bearing axis of the knee joint, reducing stress on the damaged cartilage. This is a very carefully planned procedure based on detailed biomechanical principles and pre-operative imaging and analysis.

Osteotomy is not always the first-line treatment. Alternative options depend heavily on the specific condition and patient factors. These include:

• Conservative Management: This involves non-surgical treatments such as physical therapy, medication (pain relievers, anti-inflammatory drugs), bracing, and assistive devices. This is often the initial approach for many conditions.
• Arthroscopy: Minimally invasive surgical procedure used to diagnose and treat joint problems such as meniscus tears or cartilage damage. It’s often preferable to an osteotomy if the underlying problem is amenable to arthroscopic repair.
• Joint Replacement (Arthroplasty): This involves replacing the damaged joint surface with prosthetic components. It’s considered when conservative treatments and other less invasive surgeries have failed, or when the damage is too extensive for an osteotomy to be effective.
• Other surgical procedures: Depending on the specific bone or condition, other procedures like tendon repair, ligament reconstruction, or bone grafting might be considered.

The choice of treatment is always individualized based on the patient’s age, activity level, overall health, and the severity of the condition.

Counseling patients about osteotomies requires a careful and thorough approach. It involves clearly explaining:

• The nature of the condition: A clear explanation of the diagnosis, its progression, and how it affects the patient’s daily life is crucial.
• Osteotomy as a treatment option: I explain what an osteotomy involves, its purpose, and how it addresses the specific problem.
• Benefits: I discuss the potential improvements in pain, function, mobility, and quality of life.
• Risks: I candidly discuss potential complications such as infection, non-union (failure of the bone to heal), malunion (healing in an incorrect position), nerve or blood vessel damage, and implant failure. I also address the possibility of the osteotomy not being entirely successful.
• Alternative treatments: I carefully explain the advantages and disadvantages of other treatment options.
• Recovery process: I outline the expected recovery timeline, including post-operative care, physical therapy, and activity restrictions.

Throughout the counseling process, I aim to answer all questions honestly, ensuring the patient feels informed and empowered to make an informed decision. It is important to foster open communication and address any anxieties the patient might have.

Postoperative infection after an osteotomy is a serious complication that requires prompt and aggressive management. The treatment strategy depends on the severity of the infection.

• Diagnosis: Early detection is key. This involves monitoring the patient closely for signs and symptoms such as fever, pain, swelling, redness, and drainage at the surgical site. Laboratory tests (blood cultures, wound cultures) confirm the presence and identify the type of bacteria.
• Debridement: Surgical removal of infected tissue and foreign material (e.g., parts of the implant) is often necessary. This can involve a repeat surgery to clean the infected area thoroughly.
• Antibiotic Therapy: Intravenous antibiotics are typically administered, often targeting the specific bacteria identified in the cultures. The duration of antibiotic therapy depends on the severity of the infection and the patient’s response to treatment.
• Wound Care: Careful wound management, including regular dressing changes and wound irrigation, is essential to promote healing.
• Possible Implant Removal: In severe cases, complete removal of the implant might be necessary to control the infection. This often necessitates subsequent bone grafting or other reconstructive procedures.

The management of a postoperative osteotomy infection is a complex process requiring a multidisciplinary team approach involving surgeons, infectious disease specialists, and other healthcare professionals.

Advancements in osteotomy techniques are focused on improving accuracy, minimally invasiveness, and patient outcomes. Some key developments include:

• Computer-assisted surgery (CAS): CAS uses 3D imaging and computer software to plan and guide the osteotomy, enhancing accuracy and precision.
• Navigation systems: These systems provide real-time feedback during surgery, allowing surgeons to make adjustments and ensure precise bone cuts.
• Minimally invasive techniques: Smaller incisions and less tissue dissection reduce trauma and improve recovery times.
• New implant designs: Improved implant materials and designs aim to minimize stress shielding and improve bone integration.
• 3D-printed implants: Personalized implants tailored to the patient’s anatomy can provide improved fit and function.
• Biologic augmentation techniques: The use of bone morphogenetic proteins (BMPs) and other growth factors to stimulate bone healing and reduce the risk of non-union.

These advancements aim to make osteotomies safer, more effective, and less invasive, improving patient recovery and overall outcomes.

One challenging case involved a young athlete with a complex malunion of the tibia following a high-energy trauma. The deformity resulted in significant leg length discrepancy and severe knee pain. Standard corrective osteotomy was not feasible due to the extensive bone deformity and scar tissue.

To address this, we utilized a combined approach: I performed an Ilizarov external fixation to gradually correct the leg length discrepancy and angulation. This allowed for gradual bone remodeling and minimized the risk of complications associated with a single-stage corrective osteotomy. Simultaneously, we addressed the soft tissue contractures through serial manipulation and physical therapy. After several months of gradual correction, the Ilizarov frame was removed, and a bone graft was performed to ensure solid bone healing. The outcome was excellent with restoration of near-normal leg length and significant improvement in knee function and pain levels.

This case highlighted the importance of individualized treatment planning and utilizing a multimodal approach to address complex deformities, leveraging the strengths of different techniques to achieve optimal outcomes.