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OJHAS Vol. 11, Issue 1:
(Jan-Mar 2012) |
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| Reanalysis of Agelietti
Procedure (A Method of Corrective Supracondylar Femoral Osteotomy) |
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Sharat Agarwal, Asst. Professor (Ortho
& Trauma), Department of Orthopedics
& Trauma, North Eastern Indira Gandhi
Regional Institute of Health & Medical Sciences (NEIGRHMS), Shillong. |
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Address for Correspondence |
Asst. Professor (Ortho
& Trauma),
Department of Orthopedics
& Trauma,
North Eastern Indira Gandhi
Regional Institute of Health & Medical Sciences (NEIGRHMS),
Shillong, India.
E-mail:
drsharat88@yahoo.com |
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Agarwal S. Reanalysis of Aglietti
Procedure (A Method of Corrective Supracondylar Femoral Osteotomy). Online J Health Allied Scs.
2012;11(1):12 |
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Submitted: Oct 10,
2011;
Accepted: Mar 24, 2012; Published: Apr 15, 2012 |
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| Abstract: |
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Objective: Supracondylar femoral osteotomy is the time tested
method, used for correcting the angular (varus & valgus) deformities
at the knee. Traditionally, Coventry type of osteotomy where a medial
or lateral based wedge of bone is removed or an open wedge osteotomy
is made & the space filled with bone graft, is done to achieve the
desired correction. This osteotomy is subsequently stabilized with Kirschner
wires or plates & screws. Later the limb is externally supported
in brace or plaster cast. Here we present a case
series of 10 cases, where we have analyzed the efficacy of Aglietti
procedure, as a method of femoral supracondylar osteotomy for correcting
the valgus deformity at the knee. Methods: Ten valgus adolescent knees were operated
in 7 patients by following the Aglietti procedure for correcting the
angular deformity at the knee. The results were analyzed taking into
consideration the operating time, blood loss during surgery estimated
by the number of surgical mops used, stability of the osteotomy in the
post-operative period & ultimate range of motion (ROM) obtained
at the end of 6 months after the surgery. Results: The average age of patients dealt with was 12.6 years
(n=7) with females predominating (n=5) against 2 males. The average
time was 47.5 minutes. The average size of the surgical mops used was
15x20 cms. Surgical mops used per patient were 1.6. The average range
of flexion achieved at the end of 6 months after surgery was 131.45
degrees ( Rounded average to a measurable value being 131 degrees). Conclusion: In our case series we found
Aglietti procedure as an effective method
to correct the valgus deformity in adolescent knees. Supracondylar femoral osteotomies are not only for varus an valgus corrections; this osteotomy
is used as well for rotation correction and flexion and extension correction,
mainly in CP patients. But we used the Agelietti procedure for the correction of angular deformities(varus/valgus) in patients of nutritional
rickets. However
more number of cases need to be done to make a final conclusion of establishing
the superiority of this method over other methods.
Key Words:
Aglietti procedure; Supracondylar femoral osteotomy;
Valgus knee
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Supracondylar femoral
osteotomy is one of the most commonly performed procedure to correct
the angular deformities at knee due to varied etiologies. Worldwide
Coventry(1-5) method of supracodylar femoral osteotomy is widely
prevalent where focus is on to remove or create a wedge of bone using
bone graft, enough to correct the deformity. There are other various
forms of similar procedures available, described by different authors
for correcting the valgus or varus deformities at the knee. Here, we
analysed the efficacy of the Aglietti procedure(6) in correcting the
valgus deformity in adolescent post-rachetic patients with a good functional
outcome.
Aim: To analyze the efficacy
of Aglietti procedure for correcting the valgus deformity at knee in
terms of operating time, per-operative blood loss, efficacy of stability
of osteotomy, starting of post operative rehabilitation & functional
outcome in relation to final range of motion (ROM) – flexion after
3 months of surgery.
Ten adolescent valgus
knees (3 patients with bilateral knee deformity & 4 patients with
unilateral knee deformity) were selected for the procedure. The patients
attended the out patient department of Orthopedics & trauma at NEIGRIHMS,
Shillong. The cause of the deformity was found to be post ricketic in
all the patients. Those who presented with active rickets were treated
with vitamin D & calcium supplementation. The outcome of the treatment
was followed up with serial serum calcium & bone specific alkaline
phosphatase levels & radiological evidence of healing of rickets
with occurrence of zone of provisional calcification in the metaphysis.
Simultaneously, co-existing anemia was also treated, if present. Anemia
was found coexisting in 4 patients, since the nutritional deficiency
is quite prevalent in the north-eastern part of India. Preoperative
scanogram of the lower limbs was performed to assess the desired valgus
correction (average 6 degrees valgus at knee in bilateral cases &
similar to the other knee in unilateral cases). Patient was placed in
supine position and all the operations were performed under general
anesthesia & with upper thigh tourniquet in place. A 5 cm. long
medial paramedian incision was made in line with the medial margin of
patella. Superficial & deep fascia was incised. The distal femur
was exposed subperiosteally by following the interval behind the medial
margin of vastus medialis muscle (subvastus). Growth plate was identified
by the leash of epiphyseal vessels & firm adherence of periosteum
& confirmed finally by the image intensifier. Drill holes were made
in the medial cortex in the V-fashion in sagittal plane with the apex
of V proximal to the growth plate. Osteotomy was completed by osteotome
after joining the drilled holes. The bony cortical apex at the medial
side of this V was removed with bone-nebular or rongeur. The medial
angular displacement was done in coronal plane to achieve the desired
correction. Finally, the osteotomy was stabilized using bone staples.
Wound was closed in layers after securing hemostasis. Tourniquet deflated & the
limb was subsequently immobilized in the above knee plaster of Paris
cylinder cast. Post operative antero-posterior
& lateral radiographs of the knee showing the V shaped osteotomy fixed with staples
have been shown below (Fig.1 & 2). Postoperative wound inspection
was done at 5th postoperative day & suture removal thereafter
on 14th day. There was no case of wound infection & all
wounds healed well. At 6 weeks, postoperative radiographs were repeated
(antero-posterior & lateral radiographs) to assess any change in
the alignment or loosening of staples. Once they were ruled out, rehabilitation
in the form of active & active assisted range of motion of knee
started in brace which was discontinued at 3 months when all osteotomies
found united. The final assessment of range of motion was done at the
end of 6 months after surgery.
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Figs. 1 and 2: Post operative antero-posterior
& lateral radiographs of the knee showing the V shaped osteotomy
fixed with staples |
The average age of patients
dealt with was 12.6 years (n=7) with females predominating (n=5) against
2 males. The average time was 47.5 minutes. The average size of the
surgical mops used during surgery was 15x20 cms. The number of the surgical
mops used per patient was 1.6. The average range of flexion of the knee
achieved at the end of 6 months was 131.45 degrees (Rounded off to the
nearest measurable value of 131 degrees). The data distribution of
the patients in the study is shown below in the Table)
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Table showing data distribution of patients |
Patient No. |
Age (years) |
Sex |
Operating time (min.) |
Nos. of sponges size-15x20 cms. used |
Post 6 months ROM (Flexion in degrees) using goniometer |
1 |
16 |
F |
40 |
1 |
0-125 |
2 |
14 |
F |
45 |
2 |
0-125 |
3 |
15 |
F |
40 |
1 |
0-130 |
4 |
16 |
M |
40 |
1 |
0-135 |
5 |
12 |
F |
50 |
2 |
0-135 |
6 |
13 |
M |
45 |
2 |
0-135 |
7 |
12 |
F |
50 |
2 |
0-135 |
Deformity correction is
required when the valgus deformity at the knee is more than 12-15 degrees
or the plane of the knee joint deviates from horizontal by more than
10 degrees. Coventry method of distal femoral osteotomy is widely practiced
through out the world. Here a wedge of bone is removed from distal femoral
metaphysis based on the measurement on preoperative roentgenograms,
to achieve desired correction of the angular deformity. Subsequently
it is fixed with internal fixation device using plates & screws
or crossed K-wires. Similarly various such procedures are described
by various authors like Mc Dermott et al(7), Healy et al(8,9) and Debeyre
et al.(10) We analyzed in our case series Aglietti procedure of supracondylar
femoral osteotomy which was described in 1987. In their method, Aglietti
etal. described a supracondylar femoral osteotomy in which the osteotomy
is V – shaped in the sagittal plane with its apex just superior to
the femoral condyles. They believed this osteotomy has advantages that
no internal fixation is needed & alignment can be adjusted in the
postoperative cast. We performed the same procedure in case of adolescent
patients with valgus deformity of the knee. However, we used titanium
staples as the supplemental mode of internal fixation which was easy
to use, less time consuming & a dependable method for achieving
additional stability at the site of osteotomy. The results obtained
in our short series of 10 cases in relation to the total time required
for the procedure, average per-operative blood loss & subsequent
recovery of range of motion of the knee, are quite encouraging.
We conclude that the Aglietti
procedure of supracondyar femoral osteotomy is a noble method &
can be more widely used to achieve correction of valgus deformity of
knee in adolescent post-rachetic patients. This small case series has
used a simple methodology of assessing the final outcome of the procedure
by deformity correction and establishing good functional range of motion
of the knee. The aim was to highlight the basic procedure which can
be performed easily and does not require a specialized set up and can
easily be practiced, with minimal internal stabilization of the osteotomy
using bone staples and plaster of paris application, for the correction
of the angular deformities of the knee . Not much literature is available
on this easy to do procedure and so further evaluation is required to
assess it’s efficacy in such deformities.
I acknowledge the help
given by Dr. Manika Agarwal, Ass. Professor (Obs & Gynaecs) , NEIGRIHMS,
Shillong in preparing this manuscript.
- Coventry MB. Osteotomy
about the knee for degenerative and rheumatoid arthritis: indications,
operative technique, and results. J Bone Joint Surg 1973;55-A:23.
- Coventry MB et al.
A new geometric knee for total knee arthroplasty. Clin Orthop
1972;83:157.
- Coventry MB. Osteotomy
of the upper portion of the tibia for degenerative arthritis of the
knee: a preliminary report. J Bone Joint Surg 1965;47-A:984.
- Coventry MB. Upper tibial osteotomy for gonarthrosis: the evolution of the operation in
the last 18 years and long term results. Orthop Clin North Am
1979;10:191.
- Coventry MB. Proximal tibial osteotomy.
Orthop Rev 1988;17:456.
- Aglietti P, Stringa
G, Buzzi R et al. Correction of valgus knee deformity with a supracondylar
V osteotomy. Clin Orthop 1987;217:214.
- McDermott AGP, Finkelstein
JA, Farine I et al. Distal femoral varus osteotomy for valgus deformity of the
knee. J Bone Joint Surg 1988;70-A:110.
- Healy WL, Anglen JO,
Wasilewski SA, Krackow KA. Distal femoral varus osteotomy. J Bone
Joint Surg 1988;70-A:102.
- Healy WA Jr. Osteotomy about
the knee for osteoarthritis. Orthop Rev April 1975;4:37.
- Debeyre J, Farin
P. Technique d’ osteotomie intercondylienne du femur pour corriger
les deviations arthrosiques du genou. Ann Chir 1967;21:548.
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