OSTEOTOMIES AROUND THE HIP ` `

Dr.prashanth kumar

• Surgical corrective procedure used to - obtain a correct biomechanical

alignment of the extremity - achieve equivocal load transmission

• + / - removal of a portion of bone.

Objectives• Improve coverage of head• Containment of head• Moves normal articular cartilage into

weight bearing zone• Improves motion• Relieves pain• To correct leg length inequality by

shortening / lengthening

The Neck of Femur • Angulated in relation to the shaft in 2 planes : sagittal & coronal

• Neck Shaft angle– 140 deg at birth – 120-135 deg in adult

• Ante version – Anteverted 40 deg at birth– 12-15 deg in adults

Acetabular Direction • long axis of acetabulum

points – forwards : 15-200

ante version

– 450 inferior inclination ante version

Biomechanics

• Forces acting across hip joint

Body weight Abductor muscles

force Joint reaction force

defined as force generated within a joint in response to forces acting on the joint

in the hip, it is the result of the need to balance the momentarms of the body weight and abductor tension

maintains a level pelvis

Joint reaction force -2W during SLR - 3W in single leg stance -5W in walking -10W while running

Joint reaction force

Biomechanics in neck deformities :

Coxa valga• Increased neck shaft angle

• GT is at lower level

• Shortened abductor lever arm

• Body wt arm remains same

• Increased joint forces in hip during one leg stance

• Less muscle force required to keep pelvis horizontal

Coxa valga

Resultant force R is more than a normal hip

Coxa Vara • Decreased neck shaft angle

• GT is higher than normal

• Increased abductor lever arm

• Abductor muscle length is shortened

• Decreased joint forces across the hip during one leg stance

• Higher muscle force is required to keep pelvis horizontal

Coxa Vara

Resultant force R is less than a normal hip

Radiographic parameters used Centre Edge Angle Acetabular Index

• formed b/w Hilgenreiner line and a line drawn along the acetabular surface

• Newborns : 27.5° 6 months age : 23.5° 2yrs age : 20°

• Maximum upper limit : 30°

• Formed b/w Perkin line & a line that connects lateral acetabular margin to the centre of the femoral head

• Measures the position of hip

• 6-13 yrs : >19 ° >14 yrs : >25°

• Angle increases with age

CE ANGLE of WILBERG ACETABULAR INDEX

Osteotomies around the hip are classified as

Proximal Femoral Osteotomies

According to Anatomical location

1. High cervical2. Intertrochanteric 3. Subtrochanteric4. Greater TrochantericBased on displacement of distal

fragment• Torsional/derotation • Trans positional• Angulation

– adductional/varus– abductional/valgus– flexion/ extension osteotomies

Pelvic osteotomies1.Redirectional : Single Innominate – Salter Double Innominate – Sutherland Triple Innominate - Steel, Tonnis Periacetabular Osteotomies

Ganz(Bernese)Sherical acetabular osteotomies –

Ninomiya -

Dial,Wagner

2.Volume reducing : Pemberton,Dega, San Diego

3.Greater Load bearing surface :

Shelf operation ( STAHELI)Chiari Osteotomy

• Based on Indications– To obtain pain relief• Osteoarthritis.

– Pauwels varus osteotomy.– Pauwels valgus osteotomy.– McMurrays osteotomy

– In proximal femur fractures• ununited fractures of femoral neck.

– McMurry’s osteotomy.– Dickson's high geometric osteotomy.– Schanz Angulation Osteotomy.

• unstable intertrochanteric fractures.– Dimon Hughston Osteotomy.– Sarmiento’s Osteotomy

UNREDUCED CDH- Lorenz bifurcation osteotomy- Schanz low sub trochanteric osteotomy.- Pemberten acetabuloplasty.

- Salter Osteotomy

CONGENITAL COXA-VARA

- Pauwel’s Y osteotomy-ValgusIntertrochanteric osteotomy – Borden,Wagner

LEG-CALVE PERTHE’S DISEASE - Varus de-rotation osteotomy - Salter osteotomy- Shelf - Chiari osteotomy.

. AVN - Sugioka – Trans trochanteric osteotomy- Varus de-rotation osteotomy

- Pauwels Y osteotomy

SLIPPED CAPITAL FEMORAL EPIPHYSIS.• A) Closing wedge osteotomy of neck:

a. The technique of Fishb. Technique of Dunn just distal to slipc. Base of neck technique by Kramer et al d. d. Technique of Abraham et al

• B) Compensatory osteotomies: a. Ball and socket osteotomy

b. Biplanar IT osteotomy (Southwick)

OSTEOTOMIES IN PARALYTIC DISORDER OF HIP – Varus osteotomy– Rotation osteotomy– Extension osteotomy.

Pelvic Osteotomies – SALTER INNOMINATE • the entire acetabulum together with pubis and ischium is

rotated as a unitINDICATIONS: <10–15° of correction of acetabular index is

needed• CDH in children from 18 months to 6 years of age • Congenital subluxation upto early adult life.• LCPD – onset of disease after 6 yrs age - moderate – Severely affected head - loss of containmentPREREQUISITIES:-Before the osteotomy, femoral head should be positioned

opposite the level of the acetabulum achieved by period of traction

- Contractures of iliopsoas and adductor muscles must be released.

-ROM of hip must be good

Osteotomy made from AIIS

to Greater Sciatic notch

notch

Graft is taken from iliac crest and trained to the shape of a wedge

The distal segment is

shifted forward, downward and

outward

Place the graft into open segment anteriorly

Secure it by passing K-wires from proximal fragment through graft into distal fragment taking care not to enter acetabulum

Advantages: No effect on acetabular capacity Technically less demanding

Disadvantages: Relatively unstable Needs internal fixation – k wires Needs second surgery for pin removalComplications : • Neurovascular damage – Sciatic nerve, - lateral femoral cutaneous

nerve - nutrient vessels to tensor

fascia lata• Joint penetration of k-wires

SUTHERLAND Double Innominate Osteototmy

• Indication: age 8 – 15 yrs, DDH• following Salter osteotomy, - 2nd osteotomy – Pubic osteotomy - medial to obturator foramen in

the interval b/w symphysis pubis

and pubic tubercle - wedge of bone 7- 13mm in diameter just lateral to

symphysis parallel to it• Displace the acetabular fragment distally and

anteriorly

Advantages:

• Addition of pubic osteotomy increased the amount of acetabular rotation & coverage of femoral head

• Femoral head could be shifted medially , reducing the length of femoral lever arm

Triple Innominate Osteotomy - STEEL

• INDICATIONS- Adolescents & skeletally mature adults with residual dysplasia & subluxation in whom remodelling of acetabulum is no longer anticipated

• PROCEDURE-The ischium, the sup pubic ramus and ilium superior to the acetabulum is repositioned and stabilized by bone graft

1.Osteotomy made from AIIS to Greater Sciatic notch

1.Osteotomy made from AIIS

to Greater Sciatic notch

2.Superior pubic ramus is divided

posteromedially 15° from perpendicular.

. 3. Ischial ramus is divided posterolaterally at 45° from perpendicular

• ADVANTAGE S –• Better coverage of femoral head by articular cartilage • Better hip joint stability, • no need of spica cast.

• DISADVANTAGES: 1. Difficult to perform.2. Does not change the size of the acetabulum.3. It distorts the pelvis so natural child birth is impossible in

adulthood.

Periacetabular Osteotomy – GANZ (BERNESE)

• Triplaner osteotomy for adolescent and adult dysplastic hip that required correction of congruency & containment of the femoral head with little or no arthritis

• If significant degenerative changes are presents a proximal femoral osteotomy can be added.

• Approach – Smith Peterson approach

• First cut – Ischial cut , made down to the ischium, at the infracotyloid groove , begins distal to acetabulum ,directed posteriorly aiming at the ischial spine and ends at the posterior aspect of acetabulum

• Second cut - Superior ramus cut - begins just medial to the iliopectineal eminence

• Third cut - made just inferior to the anterior superior iliac spine - cut ends just lateral to the pelvic brim at the apex

between the third and fourth cuts, midway between the posterior aspect of the posterior column and the posterior wall of the acetabulum

• Fourth cut - travels down the posterior column to meet the first cut

– Advantages :• Only one approach is used.• A large amount of correction can be obtained in

all directions, including the medial and lateral planes.

• Blood supply to the acetabulum is preserved.• The posterior column of the hemipelvis remains

mechanically intact, allowing immediate crutch walking with minimal internal fixation.

• The shape of the true pelvis is unaltered, permitting a normal child delivery.

• Can be combined with trochanteric osteotomy if needed.

• Disadavntages :- learning curve is long and steep - serious complications

• Complications :- Displacement of fragments- Delayed , nonunion of pubic and ischial

osteotomies - Loss of fixation- Damage to lateral femoral cutaneous nerve( 50%

pts )- Femoral nerve palsy,- Ectopic bone formation

VOLUME REDUCING PELVIC OSTEOTOMIES

• These osteotomies correct the acetabulum while hinging on portions of the symphysis pubis and the triradiate cartilage

• Because of this second point of hinging, these osteotomies have the potential to not only reorient the acetabulum but also to reshape it

• They differ in the extent of the bone cut on the inner and outer tables of the acetabulum, the extent of the remaining hinge

PEMBERTON OSTEOTOMY

• INDICATION: - In dysplastic hips between the age of 18 months and 6 yrs,- >10-15 degrees correction of acetabular index required.- Small femoral head ,large acetabulum

• PROCEDURE- pericapsular osteotomy of the ilium • Osteotomy is made through the full thickness of the bone

from just superior to the anteroinferior iliac spine anteriorly to the triradiate cartilage posteriorly.

• The triradiate cartilage acts as a hinge on which the acetabular roof is rotated anteriorly and laterally

• ADVANTAGES: 1. Osteotomy is incomplete, therefore more stable

2. Internal fixation is not required3. Greater degree of correction can be achieved

with less rotation of the acetabulum.• DISADVANTAGES: 1. Technically more difficult2. It alters the configuration and capacity of the

acetabulum and can result in an incongruence relationship between it and femoral head, if its larger

3. Premature closer of triradiate cartilage.

DEGA OSTEOTOMY

Age : 2 – 12 yrs • - lower age limit for the osteotomy is primarily determined

by bone quality,which must be strong enough (on the younger end) to support the hinge process ,yet

• not too stiff (on the older end) to hinge plastically.• For the bone to be adequately plastic, the triradiate

cartilage should ideally be open.

Contraindications : • acetabulum that is too small to adequately contain the

femoral head, even after reorientation

CHIARI OSTEOTOMY• Greater load bearing osteotomyIndications:• Unique - only pelvic osteotomy that is indicated primarily

when the hip is incongruous and when femoral head coverage cannot be achieved by other methods of reconstruction

• recommended when the femoral head is irregular or cannot be centered in the acetabulum by abduction and internal rotation of the hip

• Can also be performed in the presence of severe instability

• prevention or treatment of pain, rather than primary improvement in hip function, is the principal objective of this procedure

TECHNIQUE :• The osteotomy is made

precisely between the insertion of the capsule and reflected head of rectus femoris.

• Ending distal to the AIIS anteriorly and in sciatic notch posteriorly.

• With a straight narrow osteotome, start osteotomy on lateral table with plane directed 10° superiorly towards inner table.

• The distal fragment is now displaced medially by forcing the limb into abduction hinging at symphysis pubis.

• It is displaced enough medially so that the proximal fragment completely covers the femoral head

i.e. about half of the thickness of bone.

• If necessary the fragments may be transfixed by screw driven obliquely.

Disadvantages• insertions of the hip

abductor muscles are displaced medially and proximally as the hip is displaced along the slope of the osteotomy

• reduce the strength of the hip abductor muscles and decrease their mechanical advantage

Technical considerations• Risk of Posterior displacement of the distal osteotomy

fragment

• Greater risk when the osteotomy is more horizontal

• osteotomy that is curved from anterior to posterior will help resist posterior displacement of the acetabulum

• A dome-shaped osteotomy also provides more anterior and posterior support to the hip capsule and femoral head

• recommended that 80% of the femoral head should be covered following displacement

SHELF PROCEDURES - STAHELI

• Primary indication : hip dysplasia with aspherical hip congruity not amenable to redirectional osteotomies.

• Secondary indication : anterolateral acetabular extension in dysplastic hips in which femoral head coverage cannot be achieved by the more commonly performed pelvic osteotomies

• Patients aged 8 years or older with Legg-Calvé-Perthes disease, who typically present with coxa magna and early lateralization of the femoral head.

• objective is to create a shelf, the size of which is decided by measuring the “width of augmentation (WA)” using the CE angle of Wilberg.

• Graft length(gl)= wa + slot depth

• Achieving a center-edge angle of 35 degrees is optimal

• Shelf is constructed over the femoral head, particularly anteriorly and laterally

• created by using local shavings of iliac bone along with a large segment of bone from the iliac wing

• A concave slab of bone is fixed over the femoral head and placed over the hip capsule and beneath the reflected head of the rectus femoris

• A buttress of cancellous bone is then constructed between this slab and the pelvis, over the acetabulum

• As the shelf matures, the contour will remodel from the pressure of the femoral head, and the bone of the shelf will hypertroph

PROXIMAL FEMORAL OSTEOTOMIESBased on the displacement of distal fragment

1.TRANSPOSITIONAL OSTEOTOMY:Longitudinal axis of distal fragment remains parallel to the longitudinal terminal axis of proximal fragment. Used in : Fracture neck of femur, OA.Eg: McMurray osteotomy, Pauwel’s osteotomy

2.ANGULATION OSTEOTOMY :

Longitudinal axis of distal fragment forms an angle with that of proximal fragment . - Sagittal plane : Extension osteotomy for FFD -Coronal plane : varus osteotomy valgus osteotomy

Based on INDICATION – Osteoarthritis of hip

• AIM OF OSTEOTOMY :

1. RELIEF OF PAIN: Mechanical : reducing the ratio between abductor and body weight lever arm, relaxing capsule.

Haemodynamic: Also by decreasing the intra osseous pressure.2. CORRECTION OF DEFORMITY: flexion, adduction, external rotation.

3. REVERSAL OF DEGENERATIVE PROCESS: helped by increase in joint space.

• Osteotomies in Osteoarthritis of hip :

–Pauwels varus osteotomy.–Pauwels valgus osteotomy.–McMurrays osteotomy

McMurray’s Displacement OsteotomyINDICATIONS: 1. Nonunion of femoral neck2. Advanced osteoarthritis .

PREOPERATIVE PLANNING :Determination of the size of the bone wedge to be removed, the position of the seating chisel which will determine the size and angle of the blade plate to be used.

AIM : – Line of weight bearing is shifted medially– Shearing force at the nonunion is decreased, because

the fracture surface has become more horizontal

• Oblique osteotomy made in the shaft of the femur -

• Its lower border on the outer margin being slightly below the level of lesser trochanter

• Terminates on the inner side b/w lesser trochanter and neck

• Shaft of femur is displaced inwards by abduction of the limb & digital pressure on the upper and outer aspect of lower fragment – complete inward displacement

Postoperative care

• Mobilize the patient as soon as symptoms permit.

• Maintain touch-down weight bearing until union occurs.

• Active and assisted range of motion exercises for the hip and knee.

• Once union occurs, unrestricted rehabilitation is possible.

Pauwels Varus OsteotomyAIM :• To elevate the greater trochanter and move

it laterally, while moving the abductor and psoas muscles medially,

• To Restore joint congruity • Decrease the force acting on the edge of the

acetabulum moves to the middle of weight bearing surface.

INDICATIONS: – Antalgic abductor limb – Abduction deformity – Painful adduction– Neck shaft angle > 135° .

CONTRAINDICATIONS:

– Fixed external rotation of > 25° – Flexion of 70° or less.

DISADVANTAGES:

• Shortens the limb to some degrees. • Creates a trendelenberg gait.• Increases the prominence of greater

trochanter.• Overloading of the medial compartment of

knee.

PAUWELS VALGUS OSTEOTOMY AIM:• To transfer the center of hip rotation medially from the

superior aspect of the acetabulum • To decrease the weight bearing area of femoral head .• Normally 15° of correction is required.

INDICATIONS: – Trendelenburg Limb – Adduction deformity– Motion in adduction beyond adduction deformity – Painful abduction

CONTRAINDICATIONS:– Flexion of less than 60°– Knock knees as this will increase the deformity at

knee.

• After insertion of guide wire & chisel 2cm proximal to osteotomy site similar to explained before :-

SCHANZ ANGULATION OSTEOTOMY

AIM : To turn the shaft from the adducted to abducted position, so that the shearing stress of weight bearing and muscle retraction becomes an impaction force.

INDICATIONS:• Nonunion fracture neck of

femur• Congenital dislocation of

hip

• The femur is cut transversely at ischial tuberosity level & the proximal fragment is adducted until it rests against the side wall of the pelvis.

• This lengthens the distance of the gluteus medius and provides a fulcrum so that adequate leverage of the muscle is obtained.

• A plate is prepared and angulated sufficiently • At operation, the bone is sectioned and the plate is

attached to proximal fragment.

• Then, the distal fragment is abducted, extended and approximated to the distal half of the plate, which is then attached.

Osteotomies in AVN – Femoral headSUGIOKA TRANSTROCHANTERIC OSTEOTOMY

• Aim : To move the involved necrotic anteosuperior segment of the femoral head from the principal weight bearing area

- Transtrochanteric rotational osteotomy- Best results for1. small / medium sized lesions ( <30% femoral

head involvement ) in young adults2. Idiopathic / posttraumatic osteonecrosis

( compared to alcohol, steroid induced AVN )

TECHNIQUE :• Through lateral

approach expose the capsule, osteotomize the greater trochanter.

• Reflect it proximally

• Incise the joint capsule circumferentially.• Carefully protect the posterior branch of medial

circumflex femoral artery at inferior edge of Quadratus femoris.

along with the attached tendon of Gluteus medius, minimus and Piriformis.

• Place two pins in greater trochanter from lateral to medial in a plane perpendicular to femoral neck.

• Make a trans-trochantric osteotomy and a second osteotomy at right angle to the first, at superior edge of lesser trochanter, to leave the lesser trochanter with distal fragment.

• After completing second osteotomy use the proximal pin to rotate proximal fragment 45-90° depending on the size of necrotic area.

• Fix the osteotomy internally with large screws and washer.

• Re-attach the greater trochanter to proximal and distal fragment with screws.

• Post op after one yr

Postoperative: skin traction is given for 2-3 weeks • active range of motion exercises of hip are begun at

10-14 days.

LEGG CALVE PERTHES DISEASE:

PATHOLOGY: • Self limited disease of avascular necrosis

of ossification center of the capital epiphysis, resulting in variable degree of deformity of femoral head.

AIM: • To prevent or minimize residual deformity of

femoral head by creating the biomechanical environment which is not detrimental to normal growth and remodeling of epiphysis.

• This is achieved by containing the femoral head within the acetabulum.

VARUS DE-ROTATION OSTEOTOMYAIM : • By reducing the ante-version and neck shaft angle to

obtain maximum coverage of the femoral head. • This osteotomy is done before 4 years of age, as

after this age, there are less chances of Acetabular remodeling.

DISADVANTAGES: 1. Excessive varus angulation that may not correct

with growth 2. Further shortening of already shortened extremity3. Possibility of a gluteus lurch produced by

decreasing the length of the lever arm of the gluteus musculature.

• The degree of de roration is estimated with the amount of internal rotation but furthur adjustments can be made during the surgery.

• If the internal rotation is severely limited even after 4 weeks of bed rest with traction

Varus osteotomy is done along with extension by giving slight backward tilt to the proximal segment.

TECHNIQUE: • With patient supine make

lateral incision from greater trochanter distally 8 to 12cm exposing lateral aspect of femur.

• Mark the level of osteotomy at the level of lesser trochanter or slightly distal.

• Insert the guide pin and do reaming of the femoral head.

• Insert the barrel guide into the back of the implanted lag screw.

• Make the osteotomy cut & tilt the head into varus .

• Using the side plate and screws firmly join the proximal and distal fragments.

• Spica cast is worn for 8-12 weeks and internal fixation can be removed after 1-2 years.

OTHER OSTEOTOMIES IN PERTHES DISEASE

1. SALTER Innominate osteotomy:

2. SHELF procedure (Staheli): If the hip is congruous, it can be performed for coxa magna and lack of acetabular coverage for the femoral head.

3. CHIARI Osteotomy: It is used as a salvage procedure to accomplish coverage of large flattened femoral head.– Technique: Described in CDH.

4. VALGUS EXTENSION osteotomy: Indicated in malformed femoral head in residual Perthe's disease with hinge abduction. – Technique: Described in Osteoarthritis

SLIPPED CAPITAL FEMORAL EPIPHYSIS

• In this condition, the epiphysis is displaced inferiorly causing adduction and external rotation deformity of the limb.

AIM: Osteotomy is performed here to reposition the femoral head (epiphysis) concentrically within the acetabulum.

INDICATIONS: – Chronic slip with moderate to severe

displacement. – Malunited slip

TWO BASIC TYPES:• Closing wedge osteotomy of neck: Usually associated

with serious complications of AVN and chondrolysis, therefore these osteotomies are not recommended. These are of four types.a. The technique of Fishb. Technique of Dunn just distal to slipc. Base of neck technique by Kramer et al d. d. Technique of Abraham et al

• Compensatory osteotomies through the Trochantric region: These osteotomies produce a deformity in the opposite direction. It includesa. Ball and socket osteotomyb. Biplane intertrochanteric osteotomy

(Southwick)

1. CUNEIFORM OSTEOTOMY OF FEMORAL NECK (FISH):

• Fish recommended this in moderate to severe slips of more than 30°.

• Capsule is incised & femoral neck is exposed.

• Locate the physis.• Determine the size of

wedge to be removed by noting the degree of slip.

• Adjacent to the epiphyseal plate, a wedge shaped piece of bone is removed with its base directed anteriorly and superiorly with apex psotero-inferiorly.

• Take care that osteotome does not penetrate the intact posterior periosteum, damaging retinacular vessels.

• Reduce the epiphysis by flexion, abduction and internal rotation of limb, taking care to put much tension on the posterior periosteum, capsule and vessels.

After reduction fix the epiphysis to neck with 2-3 pins six inches long threaded on one half of their lengths with a nut on the thread. Do not penetrate articular cartilage.

CUNIEFORM OSTEOTOMY OF FEMORAL NECK (DUNN):

• Dunn described an osteotomy for severe chronic slips in children with open physis.

• This procedure should not be done if the physis is closed.

• Anterosuperior wedge of the most superior part of the femoral neck is removed

TECHNIQUE :• Through a lateral approach

• A. Greater trochanter is detached.• B. Synovium is elevated from anterior and

postero-lateral surface of femoral neck with periosteum elevator.

• C. Head is freed of all fibrocartilage and callus.

• D. Osteotomy line on upper end of femoral neck is made for excision of trapezoid segment. ( anterosuperior wedge )

• E. Head of femur is replaced on femoral neck and three threaded Steinmann pins are used for fixation of shaft, head, and neck of femur.

• F. Two cancellous screws are used to fix greater trochanter in normal position.

SARMIENTO OSTEOTOMY

• Involves creating an oblique osteotomy of the distal fragment(valgus osteotomy) to obtain stability in unstable IT #

• Changes # plane from verticle to near horizontal • Creates contact b/w medial and posterior cortex

of proximal and distal fragments• Goal – to obtain medial stability• Adv – valgus realignment of proximal fragment

makes up for less of length at osteotomy site so that limb lengths are equal

Technique:• A 45° oblique osteotomy of distal fragment begins

just below flare of GT & crosses distally and medially to exit about 1cm distal to the apex of #

• Guide wire and then implant are inserted at 90° to plane of # of proximal fragment

• With more vertical alignment of # ,insert guide pin so that it ends up more inferiorly in the femoral head ( other wise ,the osteotomy will be placed in varus)

• Insert 135 sliding screw in usual manner • # is reduced and impacted• Medial cortex opposition and hence stability are

restored

OSTEOTOMY TO CORRECT UNSTABLE INTERTROCHANTERIC FRACTURES

• Sarmiento Technique

THANK YOU… have a nice day