Limb Realignment

Introduction

Limb realignment (“straightening the bones and joints”) is a process that is aimed at correcting any deformities of the bones and around or within the joints. The aim is to restore normal anatomy in a single bone and in relation to the whole limb, to normalise the limb’s mechanical axis. The process eliminates the abnormal forces across the joints and allows the joints normal functioning.

It prevents or slows the occurrence of late complications such as uneven wear-out of the joint cartilage and joint degeneration, that the deformities are known to cause. The procedure involves osteotomy – cutting the bone – at the level of its deformity, realigning it and fixing it within a normal position with a plate, rod or external fixation device. It is typically recommended when there is a severe and obvious visual deformity of the limb, or if there is a subtle deformity that is symptomatic (causes pain, movement restriction or instability) and conservative treatments like physical therapy, bracing, or medication fail to provide improvement. 

The primary goal of limb realignment surgery is to protect the joints from degeneration by restoring their normal alignment, alleviating pain, improving function, and, thereby enhancing the patient’s overall mobility and wellbeing.

Indications and Contraindications

Limb Realignment Indications

Limb realignment surgery is considered for a range of conditions:

  • Malalignment of a whole limb: When there are deformities within the long bones or joints of lower or upper limbs, they may appear as obvious varus, valgus or rotational limb deformities. The most obvious are so-called bowed legs or knock-knees or deformities around the elbow in the upper limbs. The realignment surgery will improve the visual appearance of the limbs and protect joints from further degeneration.
  • Joint contractures: realignment surgery can improve the position of a contracted joint and allow it to function in a better, more efficient position.
  • Osteoarthritis: In some cases of partial joint arthritis, realignment will allow to shift of load over to a healthy part of the joint, alleviating pressure off the degenerated and the painful joint surface.
  • Fractures Malunion: In cases when a fracture is healed in an abnormal position (bone angulation, rotation or shortening), a realignment surgery may be necessary to restore the bone’s normal anatomy.
  • Fractures Nonunion: In cases when a fracture does not heal because of abnormal forces across the fracture, a bone realignment will improve fracture healing.
  • Growth Plate Abnormalities: Children with growth plate abnormalities (due to injury or congenital malformations) may require limb realignment and growth plate surgery to restore normal anatomy and prevent the increase of deformities with growth.
  • Joint Instability: When ligaments around a joint are lax or damaged, realignment surgery can improve the joint stability and function.
  • Congenital Deformities: Early realignment surgery for children born with congenital limb deformities improves their function, and appearance and protects from early onset of joint degeneration.
  • Chronic Pain: Joint pain that is caused by limb malalignment needs to be addressed through joint realignment, both to control the pain and delay further joint degeneration.

 

Limb Realignment Contraindications

While limb realignment surgery is beneficial in many cases, it may not be suitable for everyone. Contraindications for this procedure include:

  • Poor General Health: Patients with significant risks associated with anaesthesia or lengthy surgical procedures may not be suitable candidates or need medical optimisation prior to the intervention.
  • Uncontrolled Infection: An active general or local infection in the affected limb may hinder the surgery or be a cause of surgery failure and bad outcomes.
  • Neurological Disorders: Conditions that affect nerve function (underlying nerve disease or prior nerve injury) may have limited benefits from realignment.
  • Advanced Joint Destruction: In cases where joint damage is beyond repair, total joint replacement may be a more predictable alternative to realignment surgery.
  • Unrealistic Expectations: Patients with unrealistic expectations about the outcomes of surgery may not be considered suitable candidates.

Benefits and Risks

Each surgical option has its own benefits and risks. The surgeon will determine the most appropriate technique for an individual orthopaedic condition, considering the patient’s general health.

Limb realignment may be a very demanding process, especially in severe deformities. It needs a multidisciplinary team approach for optimal patient preparation, surgical planning and execution as well as postoperative care. Limb realignment procedures carry potential risks, and it is crucial for patients to have a comprehensive discussion with the team to understand the potential benefits and possible complications associated with the process.

Surgical Approach

There are several surgical techniques available for limb realignment, and the choice of procedure depends on the specific condition and the patient’s individual needs. The surgeon will determine the most appropriate technique for an individual orthopaedic condition, considering the patient’s general health.

Limb Realignment Pre-Surgery Information

The following is what can be expected prior to limb realignment surgery:

  1. Patient Evaluation: A thorough assessment of the patient’s overall health, medical history, and orthopaedic condition. When necessary, your health might need optimisation and we may refer you to another specialist.
  2. Medications: Inform your healthcare provider about any medications you’re taking, as some may need to be adjusted before surgery. You should stop taking aspirin or anti-inflammatory medications 10 days prior to the surgery. Also, you should discontinue any naturopathic or herbal medications during this period.
  3. Imaging: X-rays, CT scans, and MRIs are used to evaluate the extent of damage and plan the surgery. CT scans are especially helpful in planning the surgical steps.
  4. Skin preparation: The night before and on the morning of the operation, you will be asked to wash the leg with a sponge provided at the pre-admission clinic. If there is any suspicion of an iodine allergy, a Betadine Skin test might be used.
  5. Bowel Prep: Glycerin suppositories will be provided at the pre-admission clinic, and you will need to administer them the evening prior to the surgery. An instruction leaflet will be given to guide them.
  6. Patient education: During a physiotherapy assessment, a qualified physical therapist will provide you with personalised instructions on gait training, the use of crutches, and pre- and postoperative exercises. You will be fitted with crutches to take home and practise before the surgery.

On the day of the Surgery

  • Surgical paperwork will be administered by the nurses, and the anaesthetist will meet with the patient to ask a few questions.
  • A hospital gown will be given, and the operation site will be shaved and cleaned.
  • Betadine skin prep will be applied to the area above the operation site and wrapped.
  • All x-rays are to be sent with the patient to the theatre.

Surgical Procedure

The most common surgical options include:

  • Closing Wedge Osteotomy: In this procedure, a small wedge of bone is removed from one side of the bone to correct angular deformity.
  • Opening Wedge Osteotomy: In this procedure, a bone is cut and a wedge of bone is added to the bone to correct its deformity.
  • Joint surface elevation: In this procedure an osteotomy inside a deformed joint is used to realign the joint and increase its stability.
  • Lengthening or Shortening Osteotomy: Used to correct small bone length discrepancies, this procedure involves cutting the bone and fixing it in a lengthened or shortened position.
  • Derotation osteotomy: In the procedure bone is cut transversely, rotated and fixed in a new position
  • Gradual correction: Often the deformities exist in multiple planes, are too severe to correct them acutely or need adjunct procedures, such as bone lengthening procedure. In this case a bone will be cut during the surgery and an external apparatus will be applied to allow for a gradual correction during many weeks after the initial surgery.
  • Guided growth: in children with open growth plates, the coronal deformity around the large joints can be corrected by modulation of growth around a part or a whole growth plate using temporary staples, screws or plates, until desired correction is obtained.

Post-Surgery Information

After the osteotomy, the cut bone fragments can be secured with various devices or their combinations:

  • Circular External Fixator: An external device with bars or rings will hold the bone fragments until bone healing is complete
  • Intramedullary Nailing: A metal rod is inserted inside the bone’s medullary canal to stabilise and maintain the bone’s realignment.
  • Plates and Screws Fixation: Plates and screws are used to hold the bone’s fragments in a corrected position.

 

Following the surgery, patients can expect:

  • Hospital Stay: Depending on the deformity, bone realignment might be a serious surgery. You’ll typically be admitted into a hospital for several days for monitoring, initial rehabilitation and learning how to handle realignment programs if specialized instrumentation had been used.
  • Pain Management: Pain medications will be administered to keep you comfortable. If you have an ongoing program of deformity correction long periods of pain management are usually expected.
  • Weight-Bearing: When necessary, you will remain non-weight-bearing for a period of time. Then you will commence weight-bearing gradually, with crutches, following your surgeon’s instructions.
  • Follow-Up: Regular follow-up appointments with the team will help monitor your progress and address any concerns:
  1. 1 week postop: for wound check,
  2. 2 weeks postop: for sutures removal. You may receive a correction program for your frame during this visit. In this case, you will need x-rays follow-up every two weeks, until the program has been completed.
  3. 6 weeks postop: for x-ray assessment of healing progress.
  4. Later at 3, 6, 9, 12 months postop and further annually an x-ray will be mandatory.
  • Physical Therapy: A tailored rehabilitation program will help regain strength, flexibility, and mobility and prevent joint contractures, which are common during limb lengthening.
  • Lifestyle Adjustments: Patients need to modify their activities and household environment to accommodate the lengthy recovery process, to ensure optimal healing and comfort.

Concerns

If patients are worried about their level of pain, experience significant bleeding, or notice fever or redness around the surgical site, they should contact the office immediately. If assistance is needed after hours, patients can contact the hospital where the surgery was performed, and they will contact Professor Al Muderis on their behalf.

Norwest Private Hospital: (02) 8882 8882

Macquarie University Hospital: (02) 9812 3000

Call on +61 2 8882 9011

X-ray facilities at all locations | Urgent appointments available if necessary.

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Professor Munjed Al Muderis
Professor Munjed Al Muderis is an orthopaedic surgeon and a clinical lecturer at Macquarie University and The Australian School Of Advanced Medicine. He specialises in hip, knee, trauma and osseointegration surgery. He is a fellow of the Royal Australasian College of Surgeons and Chairman of the Osseointegration Group of Australia.
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Disclaimer

Information provided via this website is for educational and communication purposes only. The material presented is neither intended to convey the only, nor necessarily the best, method or procedure, but rather represents techniques and procedures used by Professor Munjed Al Muderis. Professor Munjed Al Muderis disclaims any and all liability for injury and/or other damages which result from an individual using techniques presented on this website. Professor Munjed Al Muderis, to the best of his knowledge, believes the information presented is current and applicable to work being done by orthopaedic surgeons worldwide.