Osteotomies Around HipOsteotomies Around Hip

Dr.Rahul mohanDr.Rahul mohan

Osteotomy Osteotomy is a surgical procedure is a surgical procedure used to obtain a correct biomechanical used to obtain a correct biomechanical alignment of the extremity.alignment of the extremity.

Osteotomy can be Osteotomy can be

[1] of [1] of femurfemur&&

[2] of [2] of pelvispelvis around the acetabulum around the acetabulum

CLASSIFICATIONCLASSIFICATION[A] [A] according to displacementaccording to displacement

1. Transposition osteotomy1. Transposition osteotomy—longitudinal —longitudinal axis of distal fragment displaced parallel to axis of distal fragment displaced parallel to proximal fragment.proximal fragment.

2.Angulation osteotomy2.Angulation osteotomy—distal fragment —distal fragment angulated---can be in saggital plane or angulated---can be in saggital plane or coronal planecoronal plane

[B] [B] according to anatomic locationaccording to anatomic location

1.1. High cervicalHigh cervical

2.2. IntertrochantricIntertrochantric

3.3. SubtrochantricSubtrochantric

4.4. Greater trochantricGreater trochantric

[C] [C] according to indicationaccording to indication

NON-UNION NECK OF FEMURNON-UNION NECK OF FEMUR

Transposition osteotomyTransposition osteotomy— — Mc MurrayMc Murray

Angulation osteotomyAngulation osteotomy— — schanz schanz [better][better]

line of weight bearing shifted medially, line of weight bearing shifted medially, shearing forces at the non union site is shearing forces at the non union site is decreased, and fracture becomes more decreased, and fracture becomes more horizontal.horizontal.

Schanz osteotomySchanz osteotomy

Femur sectioned transversly at the Femur sectioned transversly at the level of ischial tuberosity—upper level of ischial tuberosity—upper fragment angulated—hitches against fragment angulated—hitches against pelvis—thus provides support &shifts pelvis—thus provides support &shifts line of weight mediallyline of weight medially

Used in non union #NOF, CDH etcUsed in non union #NOF, CDH etc

Mc Murray osteotomyMc Murray osteotomy

At the level of base of GT upwards and At the level of base of GT upwards and inwards to a point just above LT distal inwards to a point just above LT distal fragment displaced medially below fragment displaced medially below headhead

Totally abandoned now due to Totally abandoned now due to instability & shorteninginstability & shortening..

Pauwels Y osteotomyPauwels Y osteotomy

Produce valgus neck shaft angleProduce valgus neck shaft angle

Vascular proximal end of shaft Vascular proximal end of shaft displaced medially to bridge non union displaced medially to bridge non union sitesite

Ind - Ind - Nonunion # NOF with absorption Nonunion # NOF with absorption of neck & proximal displacement of of neck & proximal displacement of distal fragment .contact neck &head distal fragment .contact neck &head minimal minimal

OSTEOARTHRITIS HIPOSTEOARTHRITIS HIP

AIMAIM

To relive painTo relive pain

Restoration of motion Restoration of motion

Correction of deformity Correction of deformity

Restoration of stabilityRestoration of stability

Reversal of degenerative processReversal of degenerative process

TO RELIEVE PAINTO RELIEVE PAIN

BiomechanicalBiomechanical

reducing muscle forcereducing muscle force

displacing fulcrumdisplacing fulcrum

relaxing capsulerelaxing capsule

restoring acetabulo femoral restoring acetabulo femoral

congruencycongruency

Detailed physical examinationDetailed physical examination

Pre op x raysPre op x rays

standing AP & latstanding AP & lat

hip in maximum ABD & ADDhip in maximum ABD & ADD

if head fit in abd – varus osteotomyif head fit in abd – varus osteotomy If head fit in add – valgus ostetomyIf head fit in add – valgus ostetomy Atleast 70* free flexionAtleast 70* free flexion

2 types— 2 types— Inter trochanteric Inter trochanteric

periacetabularperiacetabular

Inter trochanteric osteotomyInter trochanteric osteotomy

Reconstuctive— to delay/prevent OA byReconstuctive— to delay/prevent OA by

restoring near normal jt restoring near normal jt

SalvageSalvage– to relieve pain and – to relieve pain and

function to delay THR function to delay THR

Reconstructive Salvage Reconstructive Salvage

<25 years <50 years <25 years <50 years

Minimal sympt Moderate to severMinimal sympt Moderate to sever

Near-normal mvt >60 degrees flexion Near-normal mvt >60 degrees flexion

Near-normal funtn Fair to poor Near-normal funtn Fair to poor

No irreversible No irreversible

changes Irreversible changchanges Irreversible chang

Congruent butCongruent but

malaligned-xray Cartilage narrowing or malaligned-xray Cartilage narrowing or

incongruityincongruity

A patient with advanced osteoarthritis A patient with advanced osteoarthritis of the hip who has of the hip who has less than 50 degrees less than 50 degrees of motion in flexion is not a good of motion in flexion is not a good candidate for intertrochanteric candidate for intertrochanteric osteotomy.osteotomy.

A hip joint with A hip joint with rheumatoid arthritis rheumatoid arthritis rarely benefits from intertrochanteric rarely benefits from intertrochanteric osteotomy.osteotomy.

Intertrochanteric osteotomy for Intertrochanteric osteotomy for treatment of osteonecrosis of the treatment of osteonecrosis of the femoral head is effective only femoral head is effective only if healthy if healthy bone can be brought into the weight bone can be brought into the weight bearing areabearing area. Extensive involvement . Extensive involvement and collapse of the femoral head are and collapse of the femoral head are contraindications.contraindications.

Osteotomy should Osteotomy should increase and not increase and not decrease decrease the weight bearing area of the the weight bearing area of the femoral head.femoral head.

Careful study of Careful study of abduction and abduction and adduction radiographic views adduction radiographic views is crucialis crucial

Fixed adduction deformity is a Fixed adduction deformity is a contraindication to varus osteotomy contraindication to varus osteotomy and fixed abduction deformity to and fixed abduction deformity to valgus osteotomy.valgus osteotomy.

Stable internal fixationStable internal fixation is important, is important, permits early motion, and enhances permits early motion, and enhances union of the osteotomyunion of the osteotomy

Recurrence of hip pain from arthritis Recurrence of hip pain from arthritis may be simulated by may be simulated by bursitis over a bursitis over a protruding internal fixation deviceprotruding internal fixation device. . Removal of the fixation device usually Removal of the fixation device usually relieves painrelieves pain

BLOUNTS INDICATIONSBLOUNTS INDICATIONS

VALGUS OSTE..YVALGUS OSTE..Y

Trendelenberg limpTrendelenberg limp

Add deformityAdd deformity

Add beyond add Add beyond add deformitydeformity

Painful abdPainful abd

VARUS OSTEO..YVARUS OSTEO..Y

Antalgic gaitAntalgic gait

Abd deformityAbd deformity

Abd beyond abd Abd beyond abd deformitydeformity

Painful addPainful add

Varus ost alone done forVarus ost alone done for

Spherical headSpherical head

Little or no acetabular dysplasiaLittle or no acetabular dysplasia

Sign of lateral overloadingSign of lateral overloading

Valgus neck shaft angle > 135*Valgus neck shaft angle > 135*

Varus osteotomy increases weight bearing area of femoral head while relaxing all three important muscle groups around hip joint.

Muller osteotomyMuller osteotomy

Pauwels osteotomy

Valgus osteotomy aloneValgus osteotomy alone

< 50 yrs OA hip dysplasia to delay THR< 50 yrs OA hip dysplasia to delay THR

66THTH decade with medial head decade with medial head osteophyte & subchondral sclerosis in osteophyte & subchondral sclerosis in lat roof lat roof

77thth decade with OA for pain relief where decade with OA for pain relief where

THR is C/ITHR is C/I

Protrusive OAProtrusive OA

Valgus osteotomy increases weight bearing area of femoral head but does not produce muscle relaxation. Muscle relaxation can be obtained by tenotomy of iliopsoas and adductor muscles.

Extension osteotomyExtension osteotomy

In patients with acetabular dysplasia In patients with acetabular dysplasia

according to Bombelliaccording to Bombelli

Periacetabular osteotomy-Periacetabular osteotomy-Ganz Ganz

One cause of early secondary arthritis One cause of early secondary arthritis of the hip is believed to be primary of the hip is believed to be primary acetabular dysplasia acetabular dysplasia in which lateral in which lateral aspect of the articular surface of the aspect of the articular surface of the femoral head uncovered. femoral head uncovered.

This results in high stresses at the This results in high stresses at the weight bearing portion of the articular weight bearing portion of the articular surfaces of the hip, leading to surfaces of the hip, leading to early early degenerative changes degenerative changes

To contain the head within the To contain the head within the acetabulum acetabulum

Improve the mechanical environment.Improve the mechanical environment.

Ganz procedure for adults or adolescent Ganz procedure for adults or adolescent with closed physiswith closed physis

If changes seen in the head also,femoral If changes seen in the head also,femoral osteotomy can be addedosteotomy can be added

AdvantagesAdvantages1.Only one approach1.Only one approach

2.large amount of correction attained.2.large amount of correction attained.

3.Blood supply to acetabulum preserved.3.Blood supply to acetabulum preserved.

4.Minimal internal fixation.4.Minimal internal fixation.

5.Shape of pelvis unaltered.5.Shape of pelvis unaltered.

6.Can b combined with trochantric osteotmy6.Can b combined with trochantric osteotmy

ComplicationsComplications

Technically Technically demandingdemanding

Insuffucient Insuffucient /eccessive /eccessive correctioncorrection

Neurovascular Neurovascular damagedamage

OsteonecrosisOsteonecrosis

non-unionnon-union

Heterotropic Heterotropic ossificationossification

Loss of fixationLoss of fixation

AVN FEMORAL HEADAVN FEMORAL HEAD

Aim is to move the necrotic portion of Aim is to move the necrotic portion of femoral head from weight bearing area.femoral head from weight bearing area.

Indicated in Ficat stage 2 & 3 with <30% Indicated in Ficat stage 2 & 3 with <30% head involvement.head involvement.

Young ,<55yrs better resultsYoung ,<55yrs better results

Post traumatic &idiopathic better than Post traumatic &idiopathic better than steroid and alcohol induced.steroid and alcohol induced.

Transtrochantric rotational Transtrochantric rotational osteotomyosteotomy

Head & Neck rotated anteriorly so that Head & Neck rotated anteriorly so that weight bearing area is changed.Normal weight bearing area is changed.Normal area should be >1/3area should be >1/3 rdrd of total articular of total articular surface.surface.

technique—technique—Sugioka.Sugioka.

..

Intertrochanteric flexion, extension, varus , Intertrochanteric flexion, extension, varus , valgusvalgus

CI CI – stage 4 EXCEPT WHEN THR CI– stage 4 EXCEPT WHEN THR CI

Valgus extension osteotomy Valgus extension osteotomy

varus derotation osteotomy of varus derotation osteotomy of AxerAxer

DDHDDH

Treatment > 2 yrs challenging because, Treatment > 2 yrs challenging because, head is more proximal and severe head is more proximal and severe contracture of the muscles.contracture of the muscles.

So femoral shortening is an essential So femoral shortening is an essential part, still if coverage is insufficient part, still if coverage is insufficient pelvic osteotomy is needed.pelvic osteotomy is needed.

Varus derotation osteotomy—enough Varus derotation osteotomy—enough in 18-36 monthsin 18-36 months

Femoral osteotomyFemoral osteotomy

1.1. Intertrochantric varus osteotomy and Intertrochantric varus osteotomy and blade plate fixation.blade plate fixation.

2.2. Femoral shortening and Femoral shortening and derotation,combined with open derotation,combined with open reduction of hipreduction of hip

3.3. Lloyd-roberts technique of Lloyd-roberts technique of intertrochantric osteotomy and intertrochantric osteotomy and fixation with coventry apparatus.fixation with coventry apparatus.

Femoral shortening and Femoral shortening and derotation,combined with derotation,combined with

open reduction of hipopen reduction of hip

Femoral shortening is necessary to Femoral shortening is necessary to reduce pressure on the reduced reduce pressure on the reduced femoral head.femoral head.

The amount of shortening may be The amount of shortening may be estimated from the preoperative supine estimated from the preoperative supine radiograph by measuring the distance radiograph by measuring the distance from the bottom of the femoral head to from the bottom of the femoral head to the floor of the acetabulum the floor of the acetabulum

The femur is transected just below the The femur is transected just below the lesser trochanter. lesser trochanter.

The hip is reduced and the distal femoral The hip is reduced and the distal femoral shaft is aligned with the proximal shaft. shaft is aligned with the proximal shaft. The amount of overlap is noted and that The amount of overlap is noted and that much shortening done much shortening done

The degree of hip decompression is The degree of hip decompression is adequate if the surgeon can, with a adequate if the surgeon can, with a moderate force, distract the reduced moderate force, distract the reduced femoral head 3 or 4 mm from the femoral head 3 or 4 mm from the acetabulumacetabulum

The position of the lower extremity should The position of the lower extremity should be in moderate internal rotation. be in moderate internal rotation. Derotation is done only when the internal Derotation is done only when the internal rotation position is severerotation position is severe

Intertrochantric varus Intertrochantric varus osteotomy and blade plate osteotomy and blade plate

fixationfixation

Lloyd-roberts technique of Lloyd-roberts technique of intertrochantric osteotomy intertrochantric osteotomy and fixation with coventry and fixation with coventry

apparatusapparatus

Pelvic osteotomyPelvic osteotomy

1.Salter innominate osteotomy1.Salter innominate osteotomy--

Used when head has been reduced or is Used when head has been reduced or is reduced by open reduction,when<15* reduced by open reduction,when<15* correction of acetabular index needed.correction of acetabular index needed.

Prerequisites Prerequisites

contracture releasedcontracture released

Head must be reduced Head must be reduced completely & completely & concentricallyconcentrically

Congruous jointCongruous joint

Good ROMGood ROM

The Salter innominate osteotomy is based The Salter innominate osteotomy is based on on redirection of the acetabulum redirection of the acetabulum as a unit as a unit by hinging and rotation through the by hinging and rotation through the symphysis pubissymphysis pubis

It is performed by making a transverse It is performed by making a transverse linear cut above the acetabulum at the linear cut above the acetabulum at the level of the greater sciatic notch and the level of the greater sciatic notch and the anterior inferior iliac spine.anterior inferior iliac spine.

Fulcrum of rotation at Fulcrum of rotation at pubic symphysis pubic symphysis

The whole acetabulum with the distal The whole acetabulum with the distal fragment of the innominate bone is fragment of the innominate bone is tilted tilted downward and laterallydownward and laterally by rotating it. by rotating it.

The new position of the distal fragment is The new position of the distal fragment is maintained by a maintained by a triangular bone graft triangular bone graft taken from the proximal portion of the ilium taken from the proximal portion of the ilium and inserted in the open wedge osteotomy and inserted in the open wedge osteotomy site.site.

Internal fixation is provided by two Internal fixation is provided by two threaded threaded Kirschner wiresKirschner wires

Kalamchi modification of the Salter osteotomy. The distal fragment is displaced into a notch on the proximal fragment.

Pembertons pericapsular osteotomyPembertons pericapsular osteotomy

The Pemberton osteotomy The Pemberton osteotomy repositions the repositions the acetabulum acetabulum to improve anterior and lateral to improve anterior and lateral coverage of the femoral headcoverage of the femoral head

The osteotomy begins anteriorly at the The osteotomy begins anteriorly at the anterior inferior iliac spine and proceeds anterior inferior iliac spine and proceeds posteriorly and inferiorly to enter the posteriorly and inferiorly to enter the triradiate cartilage posterior to the triradiate cartilage posterior to the acetabulum. acetabulum.

The path of the osteotome is controlled The path of the osteotome is controlled with image-intensified radiography. with image-intensified radiography.

As the osteotomy is opened, the As the osteotomy is opened, the acetabular fragment is pried into an acetabular fragment is pried into an anterolateral position anterolateral position and held there with a and held there with a bone graft.bone graft.

Fulcrum of rotation at Fulcrum of rotation at triradiate cartilage triradiate cartilage

This osteotomy is quite stable and This osteotomy is quite stable and does does not require fixationnot require fixation

The osteotomy hinges through the The osteotomy hinges through the triradiate cartilage, which triradiate cartilage, which reduces the reduces the volume of the acetabulum volume of the acetabulum

Contraindicated if the acetabulum is small Contraindicated if the acetabulum is small relative to the size of the femoral head. In relative to the size of the femoral head. In such cases the procedure may prevent such cases the procedure may prevent proper reduction proper reduction

A potential complication of the Pemberton A potential complication of the Pemberton osteotomy is osteotomy is premature closure of the premature closure of the triradiate cartilage triradiate cartilage caused by the caused by the osteotomy's passing through the triradiate osteotomy's passing through the triradiate cartilage.cartilage.

Another possible complication of the Another possible complication of the procedure is procedure is damage to the acetabular damage to the acetabular growth centersgrowth centers caused by an osteotomy caused by an osteotomy made too close to the acetabulammade too close to the acetabulam

Steel osteotomySteel osteotomy

For adolescents and skeletally matureFor adolescents and skeletally mature

With residual dysplasia and congruous jt.With residual dysplasia and congruous jt.

No remodelling. No remodelling.

So free a part of pelvis,creating a movable So free a part of pelvis,creating a movable segment .segment .

Dega osteotomyDega osteotomy

Trans iliac osteotomy to correct residual Trans iliac osteotomy to correct residual acetabular dysplasia,secondary to DDH.acetabular dysplasia,secondary to DDH.

They divide the anterior and middle They divide the anterior and middle portion of inner cortex,with an intact portion of inner cortex,with an intact posterior cortexposterior cortex

Sherical [dial] osteotomy-Eppright

Augmentation of acetabulamAugmentation of acetabulam

Chiari oseotomyChiari oseotomy

when it is when it is no longer possible to achieve a no longer possible to achieve a concentric reductionconcentric reduction of the hip. of the hip.

a controlled fracture through the ilium, with a controlled fracture through the ilium, with medial displacement of the acetabular medial displacement of the acetabular fragment and the intact hip capsule under fragment and the intact hip capsule under the iliumthe ilium

Over time, the Over time, the hip capsule transforms into hip capsule transforms into fibrocartilagefibrocartilage, which becomes the new , which becomes the new acetabular coverage.acetabular coverage.

Because the femoral head is covered by Because the femoral head is covered by fibrocartilage instead of repositioned fibrocartilage instead of repositioned acetabular cartilage, the Chiari osteotomy acetabular cartilage, the Chiari osteotomy is considered a is considered a salvage proceduresalvage procedure..

Shelf proceduresShelf procedures

Numerous proceduresNumerous procedures

Slotted acetabular augmentation Of Slotted acetabular augmentation Of Staheli Staheli

Wilson shelf procedureWilson shelf procedure

Slotted acetabular augmentation

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CEREBRAL PALSYCEREBRAL PALSY

Most common deformity—adduction Most common deformity—adduction deformity, can lead to scissoring deformity, can lead to scissoring gait,subluxation or dislocation.gait,subluxation or dislocation.

Technique—Root & SeigalTechnique—Root & Seigal

ADOLESCENT COXA VARAADOLESCENT COXA VARA

Crawford criteria for surgeryCrawford criteria for surgery——

problems with gait or sitting, cosmetic problems with gait or sitting, cosmetic appearance after 1yr,after stabilization, appearance after 1yr,after stabilization, also in c/c slipalso in c/c slip

2 types --through femoral neck and other 2 types --through femoral neck and other through trochantric reigion.through trochantric reigion.

Osteotomy through femoral neckOsteotomy through femoral neck

1.Cuneiform osteotomy of Fish1.Cuneiform osteotomy of Fish—assosciated with —assosciated with high AVN & chondrolysishigh AVN & chondrolysis

2. 2. 1.Cuneiform osteotomy of Dunn1.Cuneiform osteotomy of Dunn—based on the —based on the fact that—in SLIP, new bone is laid in theback of fact that—in SLIP, new bone is laid in theback of the neck and the main blood supply runs the neck and the main blood supply runs posteriorly.posteriorly.

3.Kramer /Barmada osteotomy-3.Kramer /Barmada osteotomy- at the base of the at the base of the neck,safer as line of cut is distal to blood supply.neck,safer as line of cut is distal to blood supply.

4.Extra capsular base of neck [Abraham et al]4.Extra capsular base of neck [Abraham et al]——AVN practically nil.AVN practically nil.

Cuneiform osteotomy of FishCuneiform osteotomy of Fish

Intertrochantric osteotomyIntertrochantric osteotomy

In chronic slip, produces the opposite In chronic slip, produces the opposite deformitydeformity

1.Biplane osteotomy of Southwick.1.Biplane osteotomy of Southwick.

2.Ball and socket trochantric osteotomy2.Ball and socket trochantric osteotomy

INFECTIOUS ARTHRITISINFECTIOUS ARTHRITIS

Result is a bony ankylosis.Result is a bony ankylosis.

Trochantric osteotomy usedTrochantric osteotomy used

1.Gant opening wedge osteotomy1.Gant opening wedge osteotomy

2.Whitman closing wedge osteotomy2.Whitman closing wedge osteotomy

3.Brackett ball and socket osteotomy.3.Brackett ball and socket osteotomy.

#NOF IN CHILDREN#NOF IN CHILDREN

Can be used to treat Can be used to treat the complication the complication coxa vara .coxa vara .

Valgus subtrochantric Valgus subtrochantric osteotomy by Ratliff.osteotomy by Ratliff.

OTHER INDICATIONSOTHER INDICATIONS

Perthes diseasePerthes disease

Unstable trochantric fracturesUnstable trochantric fractures

Congenital coxa vara.Congenital coxa vara.

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