Percutaneous Osteotomies in Pediatric Deformity Correction: Nickolas Nahm,, Louise Reid Boyce Nichols

Percutaneous Osteotomies
in Pediatric Deformity
Correction
Nickolas Nahm, MDa, Louise Reid Boyce Nichols, MDb,*
KEYWORDS
Percutaneous osteotomy Corticotomy Multiple drill hole osteotomy Gigli saw osteotomy
Focal dome osteotomy Lower extremity deformity
KEY POINTS
Percutaneous osteotomies decrease soft tissue injury and offer a low-energy method of cutting
the bone to address lower extremity deformities.
Types of percutaneous osteotomies include multiple drill hole osteotomy, corticotomy, and Gigli
saw osteotomy.
Deciding on the type of osteotomy to perform should take into account the anatomic location of
the osteotomy and the necessary precision of the cut, with Gigli saw osteotomies offering the
finest cut.
INTRODUCTION risk of thermal necrosis, which is associated

with poor bony healing.5 Risk of thermal necrosis
Pediatric deformity correction frequently relies with a saw may be decreased by using a start-
on the ability of bone to regenerate after an stop technique or by cooling the blade with
osteotomy rather than bone grafting.1 The cold normal saline fluid. Although percutaneous
optimal osteotomy technique achieves this goal techniques are friendlier to the periosteum and
by minimizing injury to the bone and surround- soft tissue, they require a higher level of under-
ing soft tissues and preserving the ability of standing of three-dimensional anatomy and are
bone to regenerate. Percutaneous osteotomy more technically demanding.
techniques are the best tools surgeons have to Percutaneous osteotomy techniques include
reduce injury to the soft tissue structures sur- the corticotomy,3 multiple drill hole osteot-
rounding the bony osteotomy site.2 Undertaking omy,1,2,6 and Gigli saw osteotomy.1,2,7 All of
a minimally invasive approach also reduces dam- these techniques use minimally invasive ap-
age to the vulnerable periosteal tissue and min- proaches. The corticotomy and multiple drill
imizes vascular disruption to the bone.3 To hole osteotomies produce the least heat. How-
decrease injury, the periosteum should be ever, the corticotomy is less precise than the
incised longitudinally (not transversely) and other techniques because it relies on rotational
closed whenever possible after the osteotomy osteoclasis to complete the bone cut. This ma-
is completed. neuver may result in an unpredictable bone cut
Percutaneous osteotomies use instruments and is not ideal for small structures, such as the
that are friendly to the bony structures and mini- bony structures in the foot. The Gigli saw osteot-
mize heat generation.4 Using a saw to cut bone omy produces the cleanest and most accurate
through a larger open approach increases the cut and may be most useful in areas with smaller
a
International Center for Limb Lengthening, Rubin Institute for Advanced Orthopaedics, Sinai Hospital of Balti-
more, 2401 West Belvedere Avenue, Baltimore, MD 21215, USA; b Department of Orthopaedic Surgery, Nemours
AI duPont Hospital for Children, 1600 Rockland Avenue, Wilmington, DE 19803, USA
* Corresponding author.
E-mail address: reid.nichols@nemours.org
Orthop Clin N Am 51 (2020) 345–360

https://doi.org/10.1016/j.ocl.2020.03.001
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346 Nahm & Boyce Nichols
anatomy.8 However, the regenerate after Gigli incision, and the focal dome guide is placed at
saw osteotomy may be less robust than the the CORA. The surgeon drills multiple drill holes
regenerate after multiple drill hole osteotomy, following the radius of curvature of the guide.
and performance of this osteotomy is the most Fibular osteotomy is performed through a sepa-
technically demanding.9 The multiple drill hole rate small incision distal to the level of the tibial
osteotomy is most commonly performed and focal dome osteotomy. Guide pins for screw fix-
has reliable healing capacity. This article dis- ation are placed before completion of the
cusses percutaneous osteotomy techniques osteotomy, and multiple osteotomes are used
available in lower extremity pediatric deformity. to complete the osteotomy.
To perform a multiple drill hole osteotomy of
SURGICAL TECHNIQUES the tibia, drilling is performed first from anterior
Multiple Drill Hole Osteotomy to posterior. The drill bit is then withdrawn to
This technique may be applied to several the center of the bone and redirected postero-
different anatomic sites and is useful for creating medially and posterolaterally through the far
transverse osteotomies and focal dome osteoto- cortex, being aware of the 3 neurovascular struc-
mies.3 The multiple drill hole osteotomy does tures. Similar to the femur, an osteotome is used
not require rotational osteoclasis and may be to complete the osteotomy. The osteotome is
useful in situations where a controlled osteot- first directed anterior to posterior and then post-
omy is required, such as when osteotomy needs eromedially and posterolaterally. The osteotome
to be performed adjacent to a half pin. This is then twisted 90 in order to complete the
description focuses on application of the trans- osteotomy.
verse osteotomy technique to the femoral shaft
(Fig. 1) and the supracondylar region of the fe- Corticotomy
mur (Fig. 2). In addition, the multiple drill hole The first use of the corticotomy is generally
technique is used for creating focal dome attributed to Gavriil Ilizarov.10 Through animal
osteotomies (Fig. 3) and is also useful in the studies, Ilizarov found that preservation of
proximal tibia (eg, correction of tibia vara) and endosteal tissues and blood supply improved
the distal tibia (eg, derotational osteotomies). bone regeneration. The goal of the corticotomy
After exposing the femur with a small incision, is to preserve the endosteal tissue by disrupting
drilling is performed from lateral to medial (see only the cortex with the osteotome followed by
Fig. 1). Care must be taken to avoid plunging rotational osteoclasis for completion.11,12 A cor-
past the medial cortex secondary to the location ticotomy may be used in triangular (tibia, ulna,
of the femoral artery. The size of the drill bit de- radius) and round (femur and humerus) bones.1
pends on the size of the bone. The drill is then In the tibia, a 5-mm to 10-mm incision is made
withdrawn to the center of the bone and redir- over the crest of the tibia at the level of the
ected anteromedially and posteromedially. An osteotomy. An elevator is used to lift the perios-
osteotome is then placed into the drill hole teum from bone. Importantly, the lateral border
and directed with the same trajectory used by of the tibia is straight from the anterior to poste-
the drill bit. The trajectory should be verified rior direction, whereas the medial surface is obli-
with fluoroscopy. The osteotomy is completed que. A 6.4-mm (0.25-inch) osteotome is used to
by twisting the osteotome. A similar approach cut the anterior half of the lateral cortex of the
is used in the supracondylar region of the femur tibia up to the intramedullary canal. This dis-
(see Fig. 2). tance is approximately 1 cm in adults, but
The focal dome osteotomy is a type of multi- cortical pitch may be used to guide the position
ple drill hole osteotomy and is most frequently of the osteotome. The cortical pitch represents
used in the distal femur and distal tibia. The the sound of the hammering of the osteotome
main advantage of the focal dome osteotomy when the osteotome is in cortical bone. The
is improved bony contact. However, this tech- medial periosteum is then elevated, and the
nique is more technically demanding than other medial cortex is cut using the elevator as protec-
types of multiple drill hole osteotomies. In per- tion. Again, the cortical pitch may be used for
forming a focal dome osteotomy, the pivot point guiding the osteotomy. The periosteal elevator
of the osteotomy is at the location of the center may be palpated through the subcutaneous tis-
of rotation of angulation (CORA) of the defor- sue to estimate the depth. Osteotomy of the
mity (see Fig. 3). A focal dome guide is required lateral cortex is then completed with the
for the osteotomy and facilitates precise place- elevator in place for protection. The elevator
ment of the drill holes in an arc pattern. The may be used to guide the trajectory of the
distal tibia is exposed with a longitudinal osteotome. An osteotome is placed in the lateral
Pediatric Deformity Correction 347
Fig. 1. Multiple drill hole osteotomy

of the femoral shaft. Drill holes are
made from lateral to medial, with-
drawn to the center of the femoral
shaft, and passed anteromedially
and posteromedially. The osteot-
omy is completed with an osteo-
tome. (ª 2018 Rubin Institute for
Advanced Orthopedics, Sinai Hospi-
tal of Baltimore, (Herzenberg JE, ed-
itor. The Art of Limb Alignment:
Taylor Spatial Frame. 1st ed. Balti-
more: Sinai Hospital of Baltimore,
2018.))
cortex and twisted. This maneuver spreads open osteotomy is completed with osteoclasis of the
the osteotomy site and opens the lateral cortex. tibia. A rotational force is applied to the tibia
The twisting maneuver with the osteotome is to separate the fragments. In the proximal tibia,
repeated on the medial cortex. An audible crack the distal fragment is rotated externally to avoid
should be heard both medially and laterally stretch injury to the peroneal nerve. This method
before proceeding with osteoclasis. The may also be used in other triangular bones.
Fig. 2. Multiple drill hole osteotomy

of the distal femur. In the supracon-
dylar region of the femur, the bone
is drilled from lateral to medial.
The drill is withdrawn and aimed
anteromedially and posterome-
dially. The osteotomy is completed
with an osteotome. (ª 2018 Rubin
Institute for Advanced Orthopedics,
Sinai Hospital of Baltimore, (Herzen-
berg JE, editor. The Art of Limb
Alignment: Taylor Spatial Frame.
1st ed. Baltimore: Sinai Hospital of
Baltimore, 2018.))
Fig. 3. Focal dome osteotomy of the distal tibia. (A, B) Deformity analysis is performed. (C1 and C2) The focal
dome guide facilitates placement of drill holes in an arm pattern. (D) Multiple drill hole osteotomy is made through
the guide, and the fibular osteotomy is performed with an osteotome. (E, F) Multiple osteotomes are used to com-
plete the focal dome osteotomy. (G1 and G2) Proximal and distal tibial axes are aligned. (H) Before completion of
the osteotomy, guidewires are placed for stabilization, and cannulated screws are placed for fixation. LDTA, lateral
distal tibial angle. (ª 2018 Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore.)
A corticotomy may also be used for round These steps are performed for the posterolat-
bones, including the femur and humerus.3 For eral cortex as well. The osteotome should be
the femur, a 5-mm to 10-mm incision is made oriented in a transverse fashion, parallel to the
over the lateral thigh at the level of the osteot- posterior wall of the femur. The posterior wall
omy, and blunt dissection is carried down of the femur is the thickest part of the femur
through subcutaneous tissue, fascia, and mus- because of the linea aspera. The cortical pitch
cle. A 6.4-mm (0.25-inch) osteotome is placed should be used to guide the depth of osteo-
in a longitudinal fashion down to bone. The tome advancement. Once the cortical pitch
osteotome is tapped against the bone and changes, the osteotome is out of the postero-
twisted 90 . Twisting the osteotome spreads medial cortex of the bone. A wrench or vice
the periosteum. The osteotome is then hit to grip can then be used to turn the osteotome
create a groove on the lateral aspect of the fe- 90 . Turning the osteotome in this fashion
mur. The osteotome is removed and angled in should crack the femur. Once this crack is
an anterolateral direction, with care to keep achieved, rotational osteoclasis is used to com-
the osteotome in the corner of the groove. plete the osteotomy.
Fig. 4. Gigli saw osteotomy of the proximal tibia. (A) Two transverse incisions are placed (B) with wires used as guides. Subperiosteal dissection is performed with periosteal
Pediatric Deformity Correction

elevator (C) laterally and (D) medially. (E) Tonsil clamp is placed laterally to receive the suture. (F) A right-angle clamp is loaded with suture and placed in subperiosteal location
medially. (G) Right-angle clamp is rotated to deliver suture around the posterolateral corner, and (H) suture is grasped with the tonsil clamp. (I) After suture passage, (J) the Gigli
saw is tied to the suture on the medial side. (K) A bend is placed at the end of the Gigli saw to facilitate passage around the posterolateral corner. (L) The Gigli saw is passed,
and (M) elevators are placed subperiosteally to protect the soft tissue. (N) Osteotomy is initiated. (O) Before completion of the osteotomy through the medial cortex, subper-
iosteal dissection of the medial cortex is performed with an elevator. Before exiting the medial cortex, (P) Senn retractors are placed to protect the skin. (Q) A palpable click
designates completion of the osteotomy. Efforts should be made to preserve the medial periosteum. ([A–N] ª 2013 Rubin Institute for Advanced Orthopedics, Sinai Hospital of
Baltimore; and [O–Q] ª 2019 Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore.)
349
Fig. 4. (continued)
Gigli Saw Osteotomy

cortical bone, because the saw may cause exces-
Gigli saw osteotomy is used in the tibia, midfoot,
sive heat generation and delay or prevent union.
and, less commonly, the femur. The Gigli saw
The osteotomy is performed with reciprocal
should not be used in areas with thick diaphyseal
back-and-forth motion of the Gigli saw, ensuring
Fig. 5. Supramalleolar osteotomy with Gigli saw. (A, B) Two transverse incisions of the tibia and 1 longitudinal inci-
sion of the fibula are made. Subperiosteal dissection is performed (C) laterally, (D) posteriorly, and (E) medially with
a periosteal elevator. (F, G) Suture is passed with long curved forceps from the anteromedial incision to the fibular
incision and cut. (H) Forceps are removed, and (I) suture tied to the Gigli saw, which is (J) passed from the ante-
romedial incision to the fibular incision. (K and L) A second suture is passed from the posteromedial incision to
the fibular incision and cut. (M, N) The forceps are removed, and the Gigli saw end at the fibular incision is tied
to the suture. (O) The Gigli saw is passed, being careful to avoid kinking on the lateral side. (P) The bone is cut
with reciprocal movement of the saw. (Q) Before completing the cut medially, an osteotome is placed to protect
the medial structures. (R) The osteotomy is completed and (S) the saw removed. (ª 2018 Rubin Institute for
Advanced Orthopedics, Sinai Hospital of Baltimore, (Herzenberg JE, editor. The Art of Limb Alignment: Taylor
Spatial Frame. 1st ed. Baltimore: Sinai Hospital of Baltimore, 2018.))
Fig. 5. (continued)
that the surrounding soft tissue is protected.7 to receive suture (eg, #5 polyester braided su-
The advantage of the Gigli saw osteotomy ture) placed at the posteromedial side. A right-
compared with corticotomy is that rotational angle clamp loaded with the suture is used to
osteoclasis is not required, which is particularly pass suture from posteromedial to anterolateral.
useful when a bone defect is present, and Once in position to pass the suture, the right-
when a precise cut is required in small structures, angle clamp is rotated 90 to present the suture
such as the midfoot. to the tonsil. The tonsil grasps the suture either
The metaphyseal bone of the proximal tibia at the knot or proximal to the knot. The tonsil
(Fig. 4) and distal tibia are ideal sites for Gigli should scrape along the bone as it is being
saw osteotomy.2 For the proximal tibia, 2 small passed. Whenever passing instruments, suture,
separate transverse incisions (posteromedial or saw around the tibia, the toes should be
and anterolateral) are made at the level of the observed. Flickering of the toes suggests irrita-
osteotomy. The location of the incisions is tion of the peroneal nerve.
guided by wire placement. Subperiosteal dissec- The suture is tied to the Gigli saw, and a slight
tion of the tibia is performed with a periosteal bend is placed at the end of the Gigli saw to
elevator. A tonsil clamp is placed anterolaterally ease passage around the posterolateral corner
Fig. 5. (continued)
of the tibia. The Gigli saw is then passed from

posterior to anterior using the suture. Elevators the hands close together offers more control. A
are placed subperiosteally on the medial and click may be palpated after exiting the medial
lateral sides to protect the soft tissues from the cortex with the Gigli saw. Tensioning the saw
Gigli saw. In addition, elevators ensure that the may allow it to be palpated subcutaneously.
Gigli saw is in a subperiosteal location. The Care should be taken to avoid cutting the medial
osteotomy should be performed while the sur- periosteum. The saw is then cut and retrieved
geon is standing on the medial side of the tibia from the osteotomy site.
to minimize skin issues. The 2 ends of the Gigli An inclined percutaneous Gigli saw osteot-
saw should be 90 to each other and should be omy of the tibia is also possible.1 A Kirschner
moved in a reciprocal fashion. The posterior wire is placed at the angle required for correc-
and lateral cortices of the tibia are cut with the tion. Incisions are made at the proximal and
Gigli saw under the protection of the elevators. distal ends of the wire. Subperiosteal elevation
After reaching the medial cortex, the angle of is performed laterally and medially. The eleva-
the Gigli saw is flattened, and an elevator is tion is anterior to posterior on the lateral side.
used to subperiosteally dissect the medial peri- On the medial side, the subperiosteal elevation
osteum. Before the medial cut is finalized with is performed to meet the dissection performed
the Gigli saw, 2 Senn retractors are placed to on the lateral side. Suture is passed in a similar
protect the skin. Cutting the medial cortex is manner as was performed for the proximal tibia
the most difficult part. Grasping the wire with percutaneous osteotomy. Using a 90 clamp, su-
ture is introduced subperiosteally on the medial
Fig. 6. Midfoot osteotomy performed with Gigli saw. (A, B) Four incisions are used. Subperiosteal dissection is per-
formed on the (C, D) plantar, (E, F) dorsal, and (G) medial surfaces. (H, I) Suture is passed from lateral to medial
along the plantar surface. (J, K) Gigli saw is then passed along the plantar surface from medial to lateral. (L, M)
Suture is then used to pass the Gigli saw along the medial surface. (N–P) The Gigli saw is bent to facilitate passage
along the medial surface. (Q–S) In addition, the Gigli saw is passed along the dorsal surface. (T) The osteotomy is
initiated and paused before completion along the lateral surface. (U) A periosteal elevator is placed under the
lateral periosteum, and (V) the osteotomy is completed. (W) The Gigli saw is cut and removed. ([A–M, T–W] ª
2011 Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore; and [N–S] ª 2019 Rubin Institute
for Advanced Orthopedics, Sinai Hospital of Baltimore.)
Fig. 6. (continued)
side and retrieved with a long vascular clamp on anterior to posterior through 2 small transverse
the lateral side. The suture facilitates passage of incisions. Elevators are used to protect the soft
the Gigli saw. The Gigli saw is placed distal to tissues, and the Gigli saw is used to cut the
the Kirschner wire on the lateral side and prox- bone, similar to the proximal tibia.
imal to the Kirschner wire on the medial side. In the supramalleolar region, no space exists
The Kirschner wire is used to aid in performing between the tibia and the fibula, and both the
the osteotomy. After reaching the medial cortex, tibia and the fibula are cut13 (Fig. 5). For supra-
the periosteum is elevated off the medial cortex malleolar osteotomies, 3 small incisions are
along the path of the Kirschner wire after flat- used: 2 transverse incisions over the medial tibia
tening the Gigli saw. The Gigli saw is then cut (anteromedial and posteromedial) and one lon-
and removed. A similar approach is undertaken gitudinal over the fibula.2 Subperiosteal dissec-
in the distal tibia with the Gigli saw passed tion is performed over the anterior tibia and
around the tibia in a subperiosteal fashion from anterior fibula. Placement of the fibular incision
Fig. 6. (continued)
may be guided by placing an elevator from the elevated, and an elevator used to protect the
anteromedial side and advanced over the fibula. soft tissue envelope. The Gigli saw is then used
A suture is passed from anteromedial to lateral to cut the fibula and the tibia from lateral to
with a long curved forceps. The suture is then medial, being careful to avoid kinking the saw.
tied to the Gigli saw, which is passed from ante- After the cut is complete, the Gigli saw is cut
romedial through the fibular incision. Subperios- and pulled.
teal dissection is performed on the posterior Gigli saw osteotomies may be performed in
tibia and fibula through the posteromedial inci- the midfoot at 3 levels: the neck of the talus
sion. A second suture is then passed from the and calcaneus, the cuboid-navicular, and the
posteromedial incision to fibular incision. The cuboid-cuneiform.14 The location of the osteot-
Gigli saw is then tied to the Gigli saw and passed omy depends on the apex of the deformity. Mid-
from the fibular incision to the posteromedial foot osteotomies are used for correction of
incision. The medial periosteum of the tibia is cavovarus foot deformities gradually with a
Fig. 6. (continued)
frame. This approach is especially useful in of the Gigli saw from lateral to medial or medial
young patients with small feet who cannot afford to lateral. The Gigli saw is tied to the suture and
further shortening of the foot, which happens af- passed plantar to the foot from a medial to
ter wedge osteotomies performed for acute lateral direction. The suture and saw are then
correction. Four small incisions (medial, lateral, passed through the dorsomedial incision using
dorsomedial, and dorsolateral) are made a long curved clamp. The Gigli saw is then
(Fig. 6). Subperiosteal dissection is performed passed in a subperiosteal fashion around the
through these incisions. Of note, subperiosteal dorsum of the foot. Using periosteal elevators
elevation along the plantar surface may be diffi- to protect the soft tissues, the Gigli saw is then
cult because of the concavity of the transverse used to cut the bone. The lateral periosteum is
arch. Using a mosquito clamp, the tips of the in- elevated and protected, and the cut is finished.
strument should touch bone as the dissection is The saw is then cut and removed.
completed. Suture is used to facilitate passage
In the distal femur, the multiple drill hole tech- technically demanding. Risk of neurovascular
nique is more commonly used and easier to injury as well as incomplete osteotomy is theo-
perform than Gigli saw osteotomy. However, a retically higher with percutaneous approaches.
Gigli saw osteotomy may be faster to perform Adequate subperiosteal dissection is crucial to
than the multiple drill hole technique. To avoid neurovascular injury. Maintaining subper-
perform a Gigli saw osteotomy of the distal fe- iosteal position with passing of all instruments,
mur, 2 small transverse incisions are made, 1 suture, and Gigli saw is also vital. Furthermore,
anteromedially and the other posterolaterally.1 performance of these osteotomies requires a
Two Kirschner wires may be placed to localize strong awareness of the three-dimensional anat-
the borders of the femur. Subperiosteal dissec- omy of the structure of interest. In addition,
tion is performed posteriorly and medially. A tactile and auditory feedback from the instru-
right-angle clamp is used to pass suture and is ments is a critical part of performing the osteot-
retrieved on the medial side with a long curved omies and helps in the safe and successful
clamp. Passage of the Gigli saw is facilitated by completion of the osteotomy. Performance of
the suture. The Gigli saw is used to only cut percutaneous osteotomies with an experienced
the posterior and medial cortices. Cutting into partner or mentor may ease the learning curve
the anterior cortex may damage the quadriceps for the operator and decrease risk for the patient
muscle and tendon because of saw injury. An when first performing these techniques.
osteotome may be used to complete the osteot- Previous studies comparing percutaneous
omy along the anterior cortex. osteotomy techniques do not clearly favor one
Percutaneous Gigli saw osteotomy in the technique rather than the other. In 1 study exam-
proximal femur is also not commonly used. The ining tibial lengthening without deformity
multiple drill hole and osteotome technique is correction, Eralp and colleagues16 found that
quicker and less traumatic compared with the Gigli saw osteotomy was associated with better
Gigli saw. However, the use of a Gigli saw is healing index compared with multiple drill hole
most helpful in the proximal femur when an osteotomy. Another study comparing multiple
osteotomy needs to be performed around an drill hole osteotomy with Gigli saw osteotomy
intramedullary nail.15 The Gigli saw can be found that multiple drill hole osteotomy was
used to cut the medial cortex, and osteotomy associated with incomplete osteotomy as well
of the remaining cortices is completed with an as bone fracture.17 Interestingly, this study found
osteotome. In order to introduce the Gigli saw, a lower healing index for the Gigli saw osteot-
2 lateral transverse incisions are made anterior omy compared with the multiple drill hole
and posterior to the femur. Two Kirschner wires osteotomy, which may be related to increased
may be used to localize the anterior and poste- heat generation compared with multiple drill
rior borders of the femur. Subperiosteal dissec- hole osteotomies. Further prospective, random-
tion is performed from the lateral side both ized clinical trials are required to determine the
posteriorly and anteriorly. Suture is passed efficacy of each technique.
from posterior to anterior using a 90 clamp. The senior author prefers the Gigli saw
The suture is retrieved with a long curved clamp. osteotomy in tibia vara cases using gradual
The surgeon must be certain that the dissection correction. The Gigli saw allows for a high tibial
and instruments are subperiosteal in order to osteotomy in metaphyseal bone close to the
prevent damage to the nearby neurovascular apex of the deformity when using a hexapod fix-
structures. The Gigli saw is passed around the ator and gradual correction. The correction of
femur after tying to the suture. The femur is cavovarus foot with midfoot osteotomy or low
cut from medial to lateral with the Gigli saw until supramalleolar osteotomy with hexapod fixator
it reaches the intramedullary nail. The Gigli saw are also common scenarios for this technique
is cut and removed and the remaining cortices (Figs. 7 and 8). The Gigli saw osteotomy affords
are cut with a narrow osteotome. an accurate cut, especially in the midfoot, with
minimal bone loss. Multiple drill hole osteotomy
DISCUSSION is useful in the femur, because passing the Gigli
saw may be difficult and may put neurovascular
The advantages of percutaneous osteotomies structures at risk. Multiple drill hole osteotomy
include decreased soft tissue dissection, mini- may be considered in patients requiring a diaph-
mizing trauma to adjacent tissues, preserving yseal osteotomy or dome osteotomy, which in-
the osseous blood supply, and optimizing the creases bony contact for healing.
healing environment for the osteotomy.1 How- To conclude, this article provides an overview
ever, performing percutaneous osteotomies is of percutaneous osteotomy techniques in
Fig. 7. (A, B) Midfoot osteotomy

with Gigli saw.
pediatric lower extremity deformity. The main percutaneous osteotomies, in terms of mini-
categories of percutaneous osteotomies include mizing soft tissue injury and maximizing healing
the Ilizarov corticotomy, multiple drill hole potential, have high potential benefit to the
osteotomy, and Gigli saw osteotomy. Each tech- patients.
nique has distinct advantages and disadvan-
tages and requires a certain level of experience
DISCLOSURE
to perform safely and effectively. Nevertheless,
The authors have nothing to disclose.
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mity correction using supramalleolar gigli saw

Percutaneous Osteotomies in Pediatric Deformity Correction: Nickolas Nahm,, Louise Reid Boyce Nichols

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Percutaneous Osteotomies

INTRODUCTION risk of thermal necrosis, which is associated

Orthop Clin N Am 51 (2020) 345–360

Fig. 1. Multiple drill hole osteotomy

Fig. 2. Multiple drill hole osteotomy

Pediatric Deformity Correction

Gigli Saw Osteotomy

of the tibia. The Gigli saw is then passed from

Fig. 7. (A, B) Midfoot osteotomy

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