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Osteotomy

An osteotomy is a surgical procedure that involves cutting a bone, and sometimes adding bone tissue or grafts, to reshape, realign, or adjust its length in order to correct deformities or improve function.^[1] The term derives from the Greek words "osteon" (bone) and "tome" (cutting), literally meaning "bone cutting," and it encompasses a range of techniques performed across various skeletal sites.^[2] Osteotomies are indicated primarily to address congenital, developmental, degenerative, or traumatic bone abnormalities that cause misalignment, joint instability, or uneven load distribution, often aiming to relieve pain, enhance mobility, and delay or prevent the need for joint replacement surgeries.^[3] For instance, they are commonly used in treating osteoarthritis by redistributing mechanical forces across affected joints, such as realigning the knee to offload arthritic compartments, or correcting angular deformities in the hip or spine resulting from dysplasia or prior fractures.^[1]^[4] These procedures are particularly beneficial for younger, active patients where preserving natural joint anatomy is preferable to arthroplasty.^[5] The procedure's versatility allows for application in multiple anatomical regions, with common types including high tibial osteotomy for knee varus deformities, periacetabular osteotomy for hip dysplasia, and Le Fort osteotomies for midfacial corrections in maxillofacial surgery.^[1]^[6] Techniques vary based on the goal: opening-wedge osteotomies create a gap filled with bone graft and stabilized by plates to gradually correct alignment, while closing-wedge methods remove a bone segment for immediate adjustment, and dome or rotational osteotomies address multiplanar deformities.^[3] Performed under general or regional anesthesia, the surgery typically involves precise bone cuts using saws or osteotomes, realignment guided by imaging, and internal fixation with screws, plates, or external devices to promote healing.^[1]^[3] Recovery from an osteotomy generally spans several weeks to months, beginning with immobilization via casts, braces, or crutches to protect the site, followed by progressive physical therapy to restore strength and range of motion.^[1] Success rates are high when patient selection and surgical planning are optimal, though potential complications include infection, delayed union, nerve damage, or hardware failure, necessitating careful preoperative evaluation with radiographs, CT, or MRI.^[3] Over time, advancements in fixation technology and 3D planning have refined these surgeries, making them safer and more predictable for correcting complex skeletal issues.^[3]

Overview

Definition and Classification

An osteotomy is a surgical procedure that involves the deliberate cutting and realignment of bone to correct deformities, improve joint function, or enhance cosmetic appearance, often addressing congenital, degenerative, or traumatic conditions.^[3] This technique alters the bone's alignment, length, or shape to redistribute mechanical loads, thereby relieving stress on damaged joint surfaces and potentially delaying the need for more invasive procedures like joint replacement.^[1] Primary purposes include realignment to alleviate osteoarthritis symptoms by shifting weight to healthier cartilage areas, correction of angular or rotational deformities, limb lengthening for discrepancies, and functional restoration to improve mobility in active patients.^[7] Osteotomies are classified by technique based on the method of bone cutting and stabilization. Closing-wedge osteotomy removes a wedge-shaped segment of bone to close the gap and achieve angulation, promoting direct bone-on-bone healing without grafting, and is suitable for moderate deformities.^[3] Opening-wedge osteotomy creates a controlled gap by spreading the bone ends, typically requiring insertion of a bone graft, spacer, or plate for support, and is preferred for severe malalignments or when preserving bone length is essential.^[3] Dome osteotomy involves a semicircular cut allowing rotational correction in multiple planes without translation, eliminating the need for grafts and enabling precise adjustments. Chevron osteotomy employs a V-shaped cut for fine angulation control, often used in areas requiring minimal displacement such as the first metatarsal in hallux valgus correction.^[8] Classification by purpose further delineates osteotomies into corrective, joint-preserving, and reconstructive categories. Corrective osteotomies address congenital or traumatic deformities, such as malunions or angular deviations, by restoring normal anatomy and alignment.^[3] Joint-preserving osteotomies target early-stage arthritis, particularly in the knee or hip, by unloading affected compartments to prolong native joint viability in younger patients.^[1] Reconstructive osteotomies rebuild bone defects following tumor resection, using autografts or allografts to restore structural integrity and function.^[9] Anatomically, osteotomies are performed on various bone types depending on the pathology: long bones like the femur and tibia for lower extremity realignments, flat bones such as the mandible for maxillofacial corrections, and irregular bones including vertebrae for spinal deformities.^[3] These procedures are particularly common around the hip and knee to manage osteoarthritis or instability, with site-specific adaptations detailed in dedicated sections.^[3]

Historical Development

The concept of osteotomy, involving the surgical division of bone to correct deformities, traces its origins to ancient times, with the earliest descriptions appearing in the works of Hippocrates around 415 BCE, who advocated bone sawing techniques to address skeletal malalignments and fractures.^[10] These early methods relied on rudimentary tools and focused on basic realignment without internal fixation, laying the groundwork for later refinements in orthopedic surgery. By the 19th century, advancements in anesthesia and antisepsis enabled more precise interventions, exemplified by Austrian surgeon Adolf Lorenz, who in the 1880s developed manipulative and osteotomy techniques for congenital hip dislocation, emphasizing bloodless reductions followed by bony cuts to restore joint alignment.^[11] In the early 20th century, osteotomy gained traction for treating arthritic conditions and nonunions. Similarly, British orthopedic surgeon Thomas Porter McMurray advanced proximal femoral osteotomies in the 1920s, modifying Lorenz's approach to address hip dysplasia and osteoarthritis through intertrochanteric displacement, which improved load distribution and joint congruence.^[12] The mid-20th century marked a surge in osteotomy's popularity for joint preservation, particularly in the lower extremities. In the 1960s, Mayo Clinic surgeon Mark B. Coventry popularized high tibial osteotomy (HTO) for medial compartment knee osteoarthritis, introducing a valgus-producing closing wedge technique performed proximal to the tibial tubercle to shift weight-bearing to the lateral compartment, with reported success in delaying arthroplasty.^[13] Concurrently, the AO Foundation, established in 1958 by Swiss surgeons, revolutionized osteosynthesis principles, applying rigid internal fixation with plates and screws to osteotomies, which enhanced healing and stability while reducing complications like nonunion.^[14] From the late 20th century onward, osteotomy evolved toward less invasive and technology-driven methods. Computer-assisted planning emerged in the 1990s, enabling precise preoperative simulations and navigation for correction osteotomies, improving accuracy in lower extremity alignments.^[15] By the early 21st century, minimally invasive plate osteosynthesis (MIPO) techniques, rooted in AO principles, minimized soft-tissue disruption in osteotomies. Recent developments up to 2025 include 3D-printed surgical guides and patient-specific implants, which facilitate customized corrections and have demonstrated enhanced precision in hip and knee procedures.^[16] Biologic adjuncts, such as bone morphogenetic proteins (BMPs), have been integrated to accelerate healing, with randomized trials showing faster union rates in high tibial osteotomies when BMP-6 is applied.^[17] Long-term studies from 2015 to 2025 confirm improved joint preservation, with HTO survivorship rates ranging from 44% to 93% at 15 years and reduced progression to total knee arthroplasty in appropriately selected patients.^[18]

Patient Selection

Indications

Osteotomy is indicated for correcting bone deformities, malalignments, or length discrepancies arising from congenital conditions, trauma, developmental disorders, or degenerative diseases such as osteoarthritis (OA).^[19] It is commonly used to address angular deformities from conditions like Blount's disease or growth plate injuries, which can cause progressive malalignment if untreated.^[20] In cases of OA, particularly unicompartmental involvement in weight-bearing joints like the knee or hip, osteotomy aims to offload affected areas and redistribute mechanical loads to preserve joint function.^[21] Indications vary by anatomical site; for example, in the craniomaxillofacial region, it corrects jaw or facial asymmetries, while in the lower extremities, it addresses limb length discrepancies to prevent gait abnormalities.^[22] Suitable patient demographics depend on the procedure but often include active individuals with good bone quality who would benefit from joint preservation. For lower extremity OA corrections, adults under 60 years are typical candidates, while adolescents approaching skeletal maturity are suitable for deformity realignments.^[23]^[24] Diagnostic criteria generally involve imaging evidence of malalignment or deformity, such as angular deviations on radiographs, combined with clinical symptoms like localized pain or functional impairment. For knee-specific cases, varus or valgus deformity exceeding 5-10 degrees on full-length standing X-rays may indicate suitability.^[25] Functional assessments, including gait analysis, help evaluate how malalignment contributes to symptoms.^[22] These ensure the procedure can effectively improve biomechanics, particularly in unicompartmental disease. Clinical evidence supports efficacy in selected cases, with studies showing high success in delaying joint replacement, though outcomes vary by site and patient factors.^[26] This benefit is notable in unicompartmental OA, where realignment reduces cartilage stress.^[27] Key prerequisites include adequate vascularity for healing, absence of severe joint degeneration limiting correction, and patient commitment to rehabilitation. Site-specific applications, such as periacetabular osteotomy for hip dysplasia, emphasize these for long-term preservation.^[28]^[23]

Contraindications and Risk Factors

Absolute contraindications for osteotomy include active infection at the surgical site or inadequate soft tissue coverage, due to risks of sepsis and wound issues.^[29] Severe osteoporosis (T-score below -2.5) is another barrier, increasing non-union and fracture risks. For joint-preserving osteotomies like those for OA, advanced multi-compartmental degeneration is a contraindication, as realignment benefits are limited.^[30] Relative contraindications include conditions warranting caution, such as obesity (BMI >35 kg/m²), which raises hardware failure and healing delay risks due to mechanical stress.^[31] Smoking delays bone healing by 20-30% via vasoconstriction, elevating non-union risks.^[32] Neurological disorders impairing compliance, advanced age over 65 with comorbidities (e.g., cardiovascular disease), also qualify as relative, complicating recovery.^[29] Common risk factors include postoperative infection (1-5%), often linked to contamination or diabetes.^[33] Non-union rates are 5-10%, higher in smokers.^[32] Nerve injuries, such as peroneal nerve palsy in knee procedures, affect 1-2% of patients.^[34] Thromboembolic events like deep vein thrombosis occur in up to 5-6% without prophylaxis.^[35] Intraoperative bleeding can lead to instability if unmanaged, though volumes vary by site. Mitigation strategies include preoperative smoking cessation 4-6 weeks prior to improve healing.^[32] Antibiotic protocols reduce infection, and DVT prophylaxis with anticoagulants or devices is standard.^[35] Long-term, hardware irritation may require removal in 10-20% of cases.^[36] Overall complication rates for osteotomies vary by procedure and site, with meta-analyses indicating around 15% in knee cases; higher in complex scenarios.^[36] Postoperative malalignment exceeding 3 degrees increases revision risk, emphasizing precise correction.^[36]

Surgical Procedures

Preoperative Preparation

Preoperative preparation for osteotomy begins with a comprehensive patient evaluation to ensure suitability and optimize outcomes. This includes a detailed medical history to identify comorbidities such as cardiovascular disease, diabetes, or prior surgeries that could impact healing, along with a thorough physical examination assessing range of motion, joint stability, gait, and ligament integrity.^[37] Laboratory tests are essential, typically comprising a complete blood count (CBC) to detect anemia or infection, coagulation studies (PT/PTT and INR) to evaluate bleeding risk, and metabolic panels to assess renal and hepatic function; bone density scans may be ordered if osteoporosis is suspected, particularly in older patients or those with risk factors.^[38]^[39] Imaging protocols form the cornerstone of precise preoperative planning, starting with weight-bearing anteroposterior (AP) and lateral X-rays of the affected limb to evaluate alignment and joint space narrowing under load. Full-length hip-to-ankle radiographs are critical for assessing the mechanical axis, often using the hip-knee-ankle (HKA) angle to quantify varus or valgus deformity. Computed tomography (CT) scans provide three-dimensional (3D) reconstructions for complex cases, enabling detailed modeling of bone geometry, while magnetic resonance imaging (MRI) is employed to assess soft tissue involvement, cartilage status, and ligamentous structures when indicated.^[40]^[41]^[42] Planning tools focus on achieving optimal limb alignment, with mechanical axis calculations targeting a neutral mechanical axis (0-3 degrees valgus for the knee) to redistribute load evenly across the joint; this involves measuring the line from the femoral head center to the ankle talus center on radiographs and determining the required correction angle or wedge size. Surgical simulation software, such as Osteotomy Master or similar 3D planning platforms, enhances accuracy by simulating osteotomy cuts, plate positioning, and gap sizes based on patient-specific models derived from imaging data.^[43]^[44]^[45] Multidisciplinary input is vital, involving consultations with the orthopedic surgeon for surgical strategy, the anesthesiologist to review anesthesia risks and optimize perioperative management, and physical therapists to establish baseline function and plan rehabilitation; this team also ensures informed consent, discussing procedure details, alternatives like joint arthroplasty, potential complications, and expected outcomes.^[46]^[47] Lifestyle optimization is emphasized to reduce surgical risks, including goals for weight loss in obese patients to decrease joint loading and improve mobility, smoking cessation at least 4-6 weeks prior to enhance wound healing and reduce infection rates, and preoperative rehabilitation (prehab) exercises to strengthen muscles, improve range of motion, and build endurance around the affected joint.^[48]^[49]^[50]

Intraoperative Techniques

Intraoperative techniques in osteotomy surgery begin with appropriate anesthesia and patient positioning to ensure safety and accessibility. General anesthesia is commonly employed to fully sedate the patient, while regional or spinal anesthesia may be used to numb the surgical area or lower body, depending on the procedure's extent and location.^[1] Positioning varies by anatomical site, with supine placement typical for anterior approaches and prone for posterior ones, allowing optimal access while incorporating real-time imaging such as fluoroscopy for guidance and verification of bone alignment during the operation.^[6] Fluoroscopy provides continuous intraoperative visualization to confirm cut placement and reduce positioning errors.^[51] Bone cutting follows preoperative planning to achieve precise deformity correction, utilizing tools like oscillating saws for efficient transverse or wedge-shaped incisions, manual osteotomes for controlled chiseling in delicate areas, or piezosurgery devices that employ ultrasonic microvibrations for selective bone resection with minimal soft tissue damage.^[52] Alignment jigs or computer navigation systems guide the cuts to target specific angular adjustments, such as 5-15 degrees of valgus correction in lower extremity procedures, ensuring reproducible outcomes.^[53] These methods allow for opening-wedge, closing-wedge, or dome configurations, tailored to the required realignment. Fixation stabilizes the osteotomy site to promote healing and maintain correction, employing internal hardware such as plates, screws, or intramedullary nails for rigid support in acute procedures, or external fixators for gradual distraction in complex cases.^[1] Bone grafting with autografts or allografts is often incorporated in opening-wedge osteotomies to fill gaps and enhance stability, reducing nonunion risks.^[52] Closure and hemostasis conclude the procedure, involving layered suturing of soft tissues to restore anatomy, with drains placed as needed to manage potential fluid accumulation. In limb osteotomies, tourniquets are routinely applied to create a bloodless field, minimizing intraoperative blood loss and improving visibility.^[54] Modern advancements have enhanced precision and reduced invasiveness, including minimally invasive approaches with smaller incisions and percutaneous pinning to limit tissue disruption and accelerate recovery. Robotic assistance further improves accuracy, achieving axis correction errors under 2 degrees through automated guidance and haptic feedback.^[55] These innovations, often integrated with preoperative 3D planning tools, optimize overall surgical execution.^[52]

Postoperative Management and Rehabilitation

Immediate postoperative management of osteotomy focuses on pain control, wound care, and early mobilization to minimize complications and promote recovery. Multimodal analgesia, combining nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and regional nerve blocks, is standard to manage pain, with opioids reserved for breakthrough symptoms in the first 24-48 hours. Wound care involves keeping the incision clean and dry, typically covered with a sterile dressing changed after 48 hours or as needed, while monitoring for signs of infection such as redness or drainage. Mobilization begins on postoperative day 1 with bedside exercises and assisted transfers, progressing to partial weight-bearing using crutches or a walker, often limited to toe-touch or 20-25% body weight to protect the osteotomy site. Bony union typically occurs within 6-12 weeks, assessed through serial X-rays at intervals to evaluate callus formation and alignment stability, while soft tissue recovery, including muscle strength and joint function, extends to 3-6 months. Delays in union may require extended immobilization or additional interventions. Rehabilitation is structured in phases to gradually restore function. Phase 1 (0-6 weeks) emphasizes protected weight-bearing with assistive devices, passive range of motion (ROM) exercises to prevent stiffness, and gentle isometric strengthening to maintain muscle tone without stressing the bone. Phase 2 (6-12 weeks) advances to active ROM, progressive weight-bearing toward full, and targeted strengthening exercises like straight-leg raises and stationary cycling to improve gait and stability. Phase 3 (3+ months) incorporates functional training, balance work, and sport-specific activities to achieve full return to daily or athletic demands, often guided by physical therapy. Follow-up monitoring occurs at 2, 6, and 12 weeks postoperatively, involving clinical exams for alignment, ROM, and strength, along with radiographs to confirm healing and screen for complications like infection (e.g., fever, erythema) or hardware issues. Long-term surveillance may continue annually to assess joint preservation. Successful outcomes include significant pain reduction, with visual analog scale (VAS) scores decreasing by 4-6 points at 1-year follow-up, and functional improvements such as 20-30 point gains in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. Joint preservation success rates range from 80-90% at 5-10 years, delaying the need for arthroplasty in most cases.

Osteotomies of the Lower Extremity

Hip Osteotomies

Hip osteotomies encompass a range of corrective procedures aimed at addressing structural abnormalities of the hip joint, particularly those involving the proximal femur or acetabulum, to restore biomechanics and prevent degenerative changes. These interventions are primarily indicated for conditions such as developmental dysplasia of the hip (DDH), Legg-Calvé-Perthes disease (LCPD), and early-stage avascular necrosis (AVN) of the femoral head, where the goal is to achieve adequate acetabular coverage, typically targeting a lateral center-edge (CE) angle greater than 25 degrees to improve joint stability and load distribution.^[56]^[57]^[58] Common types include proximal femoral osteotomies and periacetabular osteotomies. Proximal femoral osteotomies, such as varus or valgus corrections, are employed to address dysplastic femoral anatomy or femoroacetabular impingement (FAI) by altering the femoral neck-shaft angle or version.^[59] These are particularly useful in cases of excessive anteversion or retroversion contributing to instability in DDH or LCPD. Periacetabular osteotomies, exemplified by the Bernese or Ganz technique, reorient the acetabulum to enhance femoral head coverage without disrupting the posterior blood supply, making them suitable for adolescent and young adult patients with symptomatic dysplasia.^[56]^[60] Surgical specifics for proximal femoral osteotomies involve subtrochanteric or intertrochanteric cuts, often combined with derotation to correct version by 15-23 degrees, followed by internal fixation using blade plates, locking plates, or intramedullary nails to achieve union and alignment.^[59]^[61] In the Bernese periacetabular osteotomy, multiple pelvic cuts are made—including incomplete ischial, pubic, iliac (at a 120-degree angle), and retroacetabular osteotomies—via a modified Smith-Petersen approach, preserving the abductor musculature by avoiding stripping and completing the supra-acetabular cut under fluoroscopic guidance; the fragment is then reoriented and secured with 3.5-4.5 mm screws and Kirschner wires for stability.^[56] These techniques are performed in patients aged 10-40 years with minimal osteoarthritis (Tönnis grade <2) and preserved range of motion to optimize joint preservation.^[56] Outcomes demonstrate that hip osteotomies effectively delay the need for total hip arthroplasty, with survival rates of 80-90% at 10 years and 60-80% at 14-20 years post-procedure, alongside significant improvements in pain and function, such as Harris Hip Scores rising from approximately 64 to 87 points.^[62]^[61] Complications occur in 6-37% of cases, with heterotopic ossification affecting 7-20% of patients, often managed conservatively or with NSAID prophylaxis, though major issues like nerve dysesthesia or nonunion remain infrequent in experienced centers.^[63]^[64] Recent advances as of 2025 include the integration of hip arthroscopy with osteotomies for simultaneous intra-articular pathology management, such as labral repair during periacetabular osteotomy, yielding comparable complication rates (around 3%) and enhanced functional recovery without increased risk.^[59]^[65] Additionally, finite element modeling has emerged for preoperative stress prediction and optimization of acetabular reorientation, enabling patient-specific plans that improve contact mechanics and long-term joint survival, along with surgical navigation systems for improved precision in periacetabular osteotomy.^[66]^[67]^[68]

Knee Osteotomies

Knee osteotomies are surgical procedures designed to correct angular deformities around the knee joint, primarily to unload the affected compartment in cases of osteoarthritis or malalignment. These interventions realign the mechanical axis of the lower extremity to redistribute weight-bearing forces, thereby alleviating pain and slowing disease progression in the medial or lateral compartments. High tibial osteotomy (HTO) and distal femoral osteotomy (DFO) are the most common types, with HTO typically addressing varus deformities and DFO targeting valgus alignment.^[69]^[70] The medial opening-wedge HTO is the predominant technique for varus knees, involving a cut on the medial proximal tibia to open a wedge and shift the mechanical axis laterally, often fixed with a locking plate. Lateral closing-wedge HTO, which removes a bone wedge from the lateral tibia, is less commonly performed due to potential lateral compartment overload and fibular complications. For valgus deformities, DFO corrects the distal femur by either closing a medial wedge or opening a lateral wedge, aiming to neutralize the hip-knee-ankle (HKA) angle. These procedures are particularly indicated for medial compartment osteoarthritis with varus malalignment exceeding 3 degrees, post-traumatic malunion, or when the mechanical axis deviates medially beyond the ideal point, targeting passage through approximately 62% of the tibial plateau width (Fujisawa point) to optimize load distribution.^[69]^[70]^[71] Surgical execution of HTO typically involves biplanar osteotomy cuts positioned 10-15 mm above the tibial tubercle to preserve the tibial slope and patellar tendon insertion, enhancing stability and reducing posterior slope changes. The osteotomy is stabilized with a locking plate, such as the TomoFix system, which provides angular stability through bicortical screws and allows early weight-bearing. For large corrections exceeding 12 mm, allografts or bone substitutes are often incorporated into the wedge to promote union and prevent delayed healing, as synthetic spacers alone may insufficiently support extensive gaps. In DFO, the osteotomy is performed in the metadiaphyseal region via a subvastus approach, with direct bone apposition in closing-wedge variants to minimize leg length discrepancies. Concomitant procedures, such as meniscal repair or ligament reconstruction, may be addressed during the same surgery to optimize outcomes.^[72]^[73]^[74] Clinical outcomes demonstrate substantial pain relief in approximately 80% of patients following knee osteotomy, with improved function and delayed need for arthroplasty. Survival rates, defined as avoidance of total knee replacement, are approximately 85-95% at 10 years for patients under 55 years, particularly those with isolated medial compartment disease and preserved range of motion.^[75] Complications occur in 10-15% of cases, including peroneal nerve palsy in 2-5% (more common in valgus corrections or fibular osteotomies), hardware irritation necessitating removal in up to 70%, and delayed union in 4-14%. Long-term radiological alignment correction is reliable, with HKA angles improving from 7-8 degrees varus/valgus to near neutral.^[76]^[77]^[78] Recent advances as of 2025 include patient-matched instrumentation via 3D printing, which enhances precision in osteotomy planning and plate contouring using preoperative CT scans, reducing operative time and alignment errors compared to conventional methods. Additionally, combining HTO with cartilage restoration techniques, such as microfracture for focal defects, yields improved joint preservation in younger patients with chondral lesions, promoting fibrocartilage formation under corrected loading conditions, along with AI-based integration in surgical robots for corrective osteotomy. These innovations support outpatient feasibility and higher satisfaction rates in active individuals.^[79]^[80]^[81]

Osteotomies of the Craniomaxillofacial Region

Jaw Osteotomies

Jaw osteotomies, also known as orthognathic surgeries, involve precise cuts in the maxilla or mandible to reposition these bones, correcting dentofacial deformities that impair function, aesthetics, and quality of life.^[6] These procedures are integral to treating skeletal discrepancies where orthodontic treatment alone is insufficient, often combining maxillary and mandibular interventions for optimal occlusal harmony.^[82] Common types include the Le Fort I osteotomy for the maxilla, bilateral sagittal split osteotomy (BSSO) for the mandible, and segmental osteotomies for targeted bite adjustments.^[83] The Le Fort I osteotomy detaches the maxilla horizontally above the teeth, enabling advancement, setback, expansion, or impaction to address midfacial deficiencies.^[6] In BSSO, sagittal cuts are made along the mandibular ramus and body, allowing proximal and distal segment separation for advancement or setback, typically secured with titanium plates and screws for rigid fixation.^[84] Segmental osteotomies, such as anterior or posterior maxillary cuts, mobilize dental arches to close open bites or correct transverse discrepancies without altering the entire jaw.^[85] Indications for jaw osteotomies encompass severe Class II or III malocclusions, characterized by overjet exceeding 5 mm or reverse overjet, often leading to masticatory inefficiency and temporomandibular joint (TMJ) strain.^[82] They are also employed for facial asymmetries greater than 3 mm from trauma or congenital anomalies, and for obstructive sleep apnea (OSA) via maxillomandibular advancement exceeding 10 mm to enlarge the pharyngeal airway.^[82] In TMJ disorders, these surgeries address underlying skeletal malocclusions after conservative therapies fail.^[82] Surgical execution emphasizes virtual surgical planning (VSP), which integrates 3D imaging for preoperative simulation, achieving mean linear discrepancies under 1 mm compared to traditional methods.^[86] Rigid internal fixation with plates prevents relapse, while BSSO specifically requires careful condylar positioning to avoid sag.^[84] Procedures integrate with presurgical orthodontics for decompensation, aligning teeth to facilitate skeletal movement.^[85] Patient outcomes demonstrate high satisfaction rates of 85% or more in orthognathic cases, with improvements in occlusion, facial harmony, and psychosocial well-being.^[87] Complications include condylar sag in BSSO cases, potentially causing malocclusion, and neurosensory disturbances from inferior alveolar nerve injury in up to 20% of patients, though most resolve within a year.^[88] For OSA, maxillomandibular advancement yields success rates of 57-86%, often eliminating CPAP dependency.^[89] Recent advances by 2025 incorporate computer-aided design/computer-aided manufacturing (CAD/CAM) for patient-specific splints and cutting guides, enhancing precision and reducing operative time.^[90] These tools, combined with intraoperative navigation, support minimally invasive approaches and multidisciplinary orthodontic integration for stable, long-term results.^[91]

Chin Osteotomies

Chin osteotomies, commonly referred to as genioplasty procedures, involve surgical reshaping of the mandibular symphysis to correct aesthetic and functional chin deformities. These osteotomies are particularly effective for addressing isolated chin discrepancies without altering the overall occlusion, distinguishing them from broader jaw corrections. Sliding genioplasty, the most prevalent type, entails a horizontal cut through the chin bone that allows forward or backward sliding of the segment for advancement or reduction, respectively. Augmentation with alloplastic implants may be considered when osteotomy is unsuitable due to bone quality or patient factors, while reduction osteotomy removes prominent bone to address overprojection or vertical excess.^[92] Indications for chin osteotomies are primarily aesthetic, targeting conditions such as microgenia, characterized by an underdeveloped or retruded chin, and witch's chin deformity, which involves ptosis and redundancy of the soft tissues under the chin. These procedures are also frequently performed as an adjunct to orthognathic surgery to optimize facial harmony, particularly when pogonion projection falls below -4 mm (indicating retrognathia) or exceeds +10 mm (indicating prognathia), as measured relative to the nasion-perpendicular line in cephalometric analysis.^[92]^[93]^[94] Surgical execution of sliding genioplasty typically involves an intraoral approach with a horizontal osteotomy placed 5-7 mm inferior to the mental foramen to mobilize a full-thickness bone segment while preserving the inferior alveolar nerve. The segment is then advanced 5-15 mm anteriorly for microgenia correction, secured with step osteosynthesis using titanium plates or screws for stability, and positioned inferiorly to minimize nerve damage risk. This technique allows precise contouring and avoids extraoral incisions, promoting faster healing.^[92]^[95]^[96] Patient outcomes following chin osteotomies demonstrate high aesthetic satisfaction rates of approximately 90-93%, with predictable improvements in profile and symmetry. Complications are infrequent, with transient edema typically resolving within 2-4 weeks and infection rates around 3%; temporary neurosensory disturbances occur in about 5-7% of cases but rarely persist.^[97]^[92]^[98] Recent advances as of 2025 include the integration of 3D-printed custom plates, which enhance precision in fixation and reduce operative time through virtual planning tailored to patient anatomy. Additionally, combining genioplasty with submental liposuction has gained traction to achieve soft tissue harmony, particularly in cases of concomitant fat excess, yielding superior contour results without increasing complication risks.^[99]^[100]

Veterinary Osteotomy Procedures

Common Procedures in Animals

In veterinary medicine, osteotomies are frequently performed to address orthopedic conditions in companion animals and large animals, particularly those involving joint instability, dysplasia, and developmental deformities. Among the most common procedures are femoral head ostectomy (FHO) for hip dysplasia in dogs and cats, tibial plateau leveling osteotomy (TPLO) for cranial cruciate ligament rupture in dogs, and corrective osteotomies for angular limb deformities (ALD) in foals. Other procedures include distal femoral osteotomy for patellar luxation in dogs and specialized corrections in exotic species like birds. These interventions aim to restore mobility, alleviate pain, and prevent further joint damage, with adaptations based on species-specific anatomy and growth patterns.^[101]^[102]^[103]^[104] FHO is a salvage procedure primarily indicated for severe hip dysplasia, which is prevalent in large breeds such as German Shepherds, as well as trauma-induced fractures or Legg-Calvé-Perthes disease in small breeds like toy poodles. In cats, it addresses similar developmental or traumatic hip issues, often in younger animals where joint salvage is not feasible. The surgery involves the complete removal of the femoral head and neck through a lateral approach, allowing the body to form a fibrous pseudarthrosis that functions as a "false joint." This eliminates bone-on-bone contact and reduces pain, though it is most effective in smaller patients due to better soft tissue adaptation. Outcomes show good to excellent function in approximately 80% of small dogs and high owner satisfaction rates of 93-96% in both dogs and cats, with most achieving pain-free mobility post-recovery.^[105]^[106]^[107] TPLO is the predominant osteotomy for treating cranial cruciate ligament (CCL) rupture in dogs, a condition exacerbated by breed predispositions in athletic or large breeds like Labrador Retrievers, often linked to conformational issues or obesity. The procedure entails a curved, radial osteotomy of the proximal tibia, followed by rotation of the tibial plateau segment to neutralize the cranial tibial thrust, typically aiming to reduce the tibial plateau angle to around 5-15 degrees for biomechanical stability. A specialized locking plate secures the bone in the new position, promoting rapid healing without reliance on the ligament. Success rates for lameness relief and return to function exceed 90-95%, with over 90% of dogs achieving near-normal limb use within 12 months.^[102]^[108]^[109] Corrective osteotomies for ALD target developmental angular deviations in growing foals, such as valgus or varus deformities of the carpus or fetlock, which can arise from uneven physeal growth, nutritional imbalances, or trauma in high-performance breeds like Thoroughbreds used for racing. These procedures often involve wedge osteotomies or osteoclasis of affected long bones (e.g., radius or third metacarpal), combined with external fixators for gradual correction over days to weeks, allowing controlled realignment as the foal bears weight. In dogs, similar techniques address radius-ulna discrepancies in toy breeds due to premature physeal closure. Healing in young animals typically occurs within 4-8 weeks, faster than in adults due to robust remodeling potential.^[103]^[110]^[111] While dogs represent the primary focus for orthopedic osteotomies like FHO and TPLO to manage chronic lameness in pets, equine applications emphasize long bone corrections in foals to preserve athletic potential for racing or performance. External skeletal fixators are particularly favored in horses for their adjustability during growth phases. Overall, these procedures highlight veterinary adaptations for species variations, with postoperative rehabilitation emphasizing controlled activity to optimize outcomes.^[103]^[108]^[112]

Differences from Human Applications

Veterinary osteotomies differ from human applications primarily due to anatomical and physiological variations across species, which influence surgical planning and outcomes. Animals exhibit diverse body sizes, from small breeds like miniature pinschers to large ones like horses, necessitating customized hardware that ranges from micro-plates to heavy-duty external fixators to accommodate varying bone diameters and load-bearing capacities. Young animals often demonstrate faster bone healing rates compared to adult humans due to higher metabolic rates and robust periosteal responses; osteotomy union in small species like dogs and rabbits typically occurs in 6-12 weeks, similar to 6-12 weeks in humans.^[108]^[2] However, exotic species such as reptiles or small mammals face elevated infection risks during osteotomies due to their unique microbiomes and limited vascularity, with postoperative infection rates potentially higher than the 2-5% typically seen in human orthopedic surgery.^[113] Technique adaptations in veterinary practice emphasize practicality and cost-effectiveness, contrasting with the more standardized, technology-intensive approaches in human medicine. Salvage procedures like femoral head ostectomy (FHO) are more common in animals for severe hip dysplasia, removing the femoral head to alleviate pain without joint reconstruction, whereas human treatments prioritize joint-preserving osteotomies such as periacetabular osteotomy to maintain biomechanics in bipedal patients. Imaging limitations play a key role; routine MRI is rarely used in veterinary settings due to anesthesia risks and expense, relying instead on radiographs and CT for preoperative planning, which can lead to less precise deformity assessments compared to human protocols. Cost constraints often favor external fixators over internal plating in resource-limited practices, particularly for large animals, reducing surgical time but increasing pin-site infection risks.^[114]^[101]^[115] Indications for veterinary osteotomies frequently include preventive interventions tailored to breed predispositions and breeding goals, diverging from the reactive, symptom-driven focus in humans. For instance, early correction of angular limb deformities (ALD) in growing animals, such as radial osteotomies in dogs, aims to prevent future lameness and support reproduction, a consideration absent in human orthopedics where consent and lifestyle factors dominate. Procedures emphasize quality-of-life improvements for pets without patient input, guided by owner expectations and breed-specific issues like hip dysplasia in Labrador retrievers, leading to earlier surgical thresholds than in humans.^[116]^[117] Outcomes evaluation and ethical frameworks in veterinary osteotomy highlight shorter monitoring periods and stringent welfare standards. Follow-up typically spans 3-6 months post-surgery, focusing on functional recovery via gait analysis, in contrast to multi-year human assessments tracking long-term joint survival. Complication tolerance is lower for companion animals, where non-union rates above 5-10% prompt revisions due to owner dissatisfaction and welfare concerns, per AVMA guidelines emphasizing pain minimization and rapid return to mobility. Ethical considerations prioritize animal welfare under frameworks like the AVMA's principles, mandating justification for invasive procedures and prohibiting those solely for cosmetic enhancement in non-breeding pets.^[118]^[119] Recent advances as of 2025 have introduced veterinary-specific innovations, though adoption lags behind human applications. 3D printing enables custom implants for osteotomies, such as patient-matched plates for ALD correction in dogs, improving fit and reducing operative time by 20-30% in complex cases. Regenerative therapies like mesenchymal stem cell injections adjunct to osteotomies promote healing in osteoarthritis models, though they remain investigational in both veterinary and human medicine due to regulatory hurdles and evidence gaps, with success rates around 70-80% for pain relief in canine trials.^[120]^[121]

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Jan 2, 2022 · In veterinary patients, exogenous osteomyelitis mainly results from direct contamination, either after trauma or surgery (Gieling et al. 2019). ...Missing: exotic | Show results with:exotic
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Comparing Hip Dysplasia in Dogs and Humans: A Review - PMC
Dec 15, 2021 · The majority of early surgical treatments, like the Pemberton and Salter osteotomy used in humans are not applicable in dogs simply because CHD ...
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Imaging techniques in veterinary medicine. Part II - PubMed Central
Radiography and ultrasonography are the most used techniques in veterinary clinical practice, due to organizational, managerial and, mostly, economic reasons.Missing: adaptations | Show results with:adaptations
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Apr 23, 2025 · Surgery is recommended to fix angular limb deformities that cause symptoms. These surgeries are usually done by a board-certified veterinary ...<|separator|>
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Treatment Option 2: Double or Triple Pelvic Osteotomy (DPO/TPO) is another option for immature dogs (ideally less than 8–10 months old) with CHD but no visible ...
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Nonadherence to follow-up recommendations is common for dogs ...
The percentage of dogs and cats lost to follow-up following orthopedic surgery at an academic veterinary teaching hospital was substantial (166/485 [34.2%]).Missing: guidelines welfare
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Delayed union, non‐union and mal‐union in 442 dogs - PMC - NIH
Aug 27, 2022 · Older dogs, dogs with comminuted fractures, surgical site infection, or major implant failure were at increased odds of delayed or non‐union.Missing: tolerance | Show results with:tolerance
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3D printing for advanced surgical planning in veterinary medicine ...
Jul 8, 2025 · 3D printing has emerged as a promising tool, providing greater precision and customization of surgical procedures.
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The Pivotal Role of Stem Cells in Veterinary Regenerative Medicine ...
Nov 21, 2022 · Stem cells have so far been employed, primarily at experimental scales, to cure a wide range of illnesses in many animal species.