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Letters to the Editor to:

Scientific Articles:
Joseph J. GugenheimJr and Mark R. Brinker
Bone Realignment with Use of Temporary External Fixation for Distal Femoral Valgus and Varus Deformities
J Bone Joint Surg Am 2003; 85: 1229-1237 [Abstract] [Full text] [PDF]
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Electronic letters published:

[Read Letter to the Editor] Dr. Gugenheim responds:
Joseph J. Gugenheim, Mark R. Brinker, M.D.   (29 April 2004)
[Read Letter to the Editor] On Achieving Long Bone Lengthening or Shortening With Dome Osteotomy
S. Hankemeier, C. Krettek   (27 January 2004)

Dr. Gugenheim responds: 29 April 2004
Previous Letter to the Editor Top
Joseph J. Gugenheim,
Orthopedist
The Center for Problem Fractures and Limb Restoration, Texas Orthopedic Hospital, Houston, TX 77030,
Mark R. Brinker, M.D.

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Re: Dr. Gugenheim responds:

jig{at}fondren.com Joseph J. Gugenheim, et al.

To the Editor:

We wish to thank Dr. Hankemeier for his comments about our article "Bone Realignment with the Use of Temporary External Fixation for Distal Femoral Valgus and Varus Deformities" (J Bone Joint Surg [Am] 2003; 85:1229-1237). Dr. Hankemeier is correct that a focal dome osteotomy can achieve lengthening of the bone, depending on where the center of rotation of angulation (CORA) is located. Figure 5 in our article shows a deformed femur with the center of rotation of angulation at the intersection of the proximal axis and the distal axis. Any point on a horizontal bisector line of this angle is also a CORA. If a CORA is chosen on the convex side of the deformity, the osteotomy will be an opening wedge and will correct the deformity as well as lengthen the bone. Similarly, a CORA on the concave side of the deformity will be a closing wedge and will correct the angulation and shorten the bone. We chose a "neutral CORA." A neutral CORA will neither lengthen nor shorten the bone but will correct the angulation. We have enclosed four figures: Figure 1 shows a right femur with a juxtaaricular valgus deformity with three CORAs on the horizontal bisector line of the deformity angle at the level of the knee joint and the corresponding dome-shaped osteotomy for each CORA. Figure 2 is a neutral CORA. Figure 3 is an opening CORA. Figure 4 is an opening CORA with even more lengthening, as it is farther from the convexity of the deformity. If a lengthening CORA (instead of a neutral CORA) is chosen for a juxtaarticular distal femoral deformity, the type of deformity that we describe in our article, the offset of the bone at the osteotomy site will make it very difficult to pass an intramedullary nail, either retrograde or antegrade. For this reason, we have chosen to use a neutral CORA for our procedure, which is a variation of the focal dome osteotomy, as described in Dr. Hankemeiers references.


We thank Dr. Hankemeier for his insightful comments.

Sincerely,

Joseph J. Gugenheim, M.D.
Mark R. Brinker, M.D.
On Achieving Long Bone Lengthening or Shortening With Dome Osteotomy 27 January 2004
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S. Hankemeier,
Dr. med.
Trauma Department, Hanover Medical School,
C. Krettek

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Re: On Achieving Long Bone Lengthening or Shortening With Dome Osteotomy

hankemeier.stefan{at}mh-hannover.de S. Hankemeier, et al.

Bone Realignment with the use of temporary external fixation for distal femoral valgus and varus deformities

To The Editor:

We read with great interest the article in the July 2003 issue by Gugenheim et al.1 entitled "Bone realignment with the use of temporary external fixation for distal femoral valgus and varus deformities." We agree that essential advantages of the focal dome osteotomy are the large contact area and the reduced risk of secondary displacement. However, we feel that the statements in the discussion "preexisting shortening of the bone cannot be corrected" by focal dome osteotomy of the distal femur and "the bone is not shortened as it is with a closing wedge osteotomy" are incorrect.

Changes in leg length similar to those achieved with straight cut closing, neutral, or opening wedge procedures can be achieved with focal dome osteotomies2,4. Focal dome osteotomies can be made around the center of rotation and angulation (CORA) regardless of whether closing, neutral, or opening wedge procedures are performed. Depending on the osteotomy technique and angulation, more than 2cm in leg length differences can occur3.

Figs. 1-A and 1-B Opening CORA (Fig. 1-A) and closing CORA (Fig. 1-B) of a focal dome osteotomy. Depending on the osteotomy type and amount of angulation, the resulting leg length (L2) is increased or decreased compared to the initial leg length (L1).

Dr. med. S. Hankemeier
Professor Dr. med. C. Krettek, FRACS
Trauma Department
Hanover Medical School
Carl-Neuberg-Str. 1
D-30165 Hannover, Germany
hankemeier.stefan{at}mh-hannover.de

References

1. Gugenheim JJ and Brinker MR. Bone Realignment with the use of temporary external fixation for distal femoral valgus and varus deformities. J Bone Joint Surg [Am] 2003;85-A:1229-37
2. Hankemeier S, Paley D, Pape HC, Zeichen J, Gosling T, Krettek C. Focal dome osteotomy of the knee. Orthopäde, Springer, online publication 22.11.2003
3. Mihalko WM, Krackow KA. Preoperative Planning for Lower Extremity Osteotomies. An analysis using 4 different methods and 3 different osteotomy techniques. J Arthroplasty 2001;16(3):322-9
4. Paley D. Principles of deformity correction. New York: Springer; 2002