OSTEOTOMIES AROUND THE HIP

DR. SIDHARTH YADAV

JR 2 ORTHOPAEDICS

NKPSIMS

DEFINITION

An osteotomy is a surgical corrective procedure used to obtain a correct biomechanical alignment of the extremity so as to achieve equivocal load transmission, performed with or without removal of a portion of the bone

HISTORY

First femoral osteotomy was performed by John-Rhea, Barton in 1826 when tried to secure the motion of ankyloid hip.

1835 Sourvier performed first subtronchanteric osteotomy for the treatment of CDH.

1854 Langenback introduced sub-cutaneous osteotomy of the femur.

1918 and 19 Von Baeyer and Lorenz described bifurcation operation of upper femoral osteotomy to secure stability in old CDH.

HISTORY

1922 Schanz reported his low sub-trochanteric abduction osteotomy.

1935 Pauwels described osteotomy at intertrochanteric level adduction deformity.

1936 McMurry performed oblique displacement osteotomy for osteoarthritis of hip and non-union fracture neck of femur.

1955 Chiari did pelvic osteotomy for stable coverage of head.

Blount and Moore described excellent blade plate for fixation of high sub-trochanteric osteotomy.

BIO MECHANICS

Forces across hip joint

Body Weight

Ground reaction forces

Abductor muscle forces

2 D STATIC ANALYSIS

One legged stance 5/6 BODY WEIGHT on femoral head

The force acting on the lever arm is thrice the body weight.

Osteotomies : Increases the contact area / congruency.

Improves coverage of head.

Moves normal articular cartilage into weight bearing zone.

Restore biomechanical advantage.

OSTEOTOMY AROUND HIP

According to Anatomic Location Femoral Osteotomy

High Cervical. Intertrochanteric Osteotomy. Subtrochanteric Osteotomy. Greater Trochanteric.

Pelvic Osteotomy. Salvage Osteotomies : eg. Chiari, Shelf. Reconstructive Osteotomies : eg. Periacetabular,

Single, Double, Triple Innominate.

Contd.

Based on Indications To obtain stability

old unreduced dislocations. Lorenz bifurcation osteotomy. Schanz low subtrochanteric.

To obtain union fractures of femoral neck.

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

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

Relief of pain osteoarathritis.

Pauwel’s type I varus osteotomy. Pauwel’s type II valgus osteotomy.

To Correct deformities coxa vara slipped upper femoral epiphysis

Intracapsular cuneiform osteotomy by dunn. Compensatory Basilar Osteotomy of Femoral

Neck. Extracapsular Base-of-Neck osteotomy. Ball-and-Socket Trochanteric Osteotomy. Pauwel’s osteotomy (Y).

Contd.Contd.

Osteonecrosis of femoral head

Sugioka’s transtrochanteric osteotomy.

Varus deroation osteotomy of Axer.

In paralytic disorders of hip.

Varus Osteotomy.

Rotational Osteotomy

In congenital dislocation.

Contd.Contd.

CONTRAINDICATIONS OF OSTEOTOMY

NEUROPATHIC ARTHROPATHY INFLAMMATORY ARTHROPATHY ACTIVE INFECTIONS SEVERE OSTEOPENIA ADVANCED ARTHRITIS/ANKYLOSIS ADVANCED AGE SMOKING, OBESITY

Principles of Osteotomy

Ostoeotomy can be viewed as either Reconstructive Salvage

Femoral osteotomy to correct proximal femoral abnormalities.

FactorsFactors Reconstructive OsteotomyReconstructive Osteotomy Salvage Osteotomy Salvage Osteotomy

Age Age Generally < 25 years Generally < 25 years Generally < 50 years Generally < 50 years

(Some biological Plasticity (Some biological Plasticity

Remains) Remains)

Symptoms Symptoms Minimal (Out Progressive) Minimal (Out Progressive) Moderate to Severe Moderate to Severe

Motion Motion Near Normal Near Normal > 60> 6000 Flexion Flexion

Function Function Near Normal Near Normal Fair to Poor Fair to Poor

Pthoanatomy Pthoanatomy No Irreversible Changes No Irreversible Changes Irreversible Changes Irreversible Changes

RoentgenograpRoentgenograp

hy hy Congruent but Malaligned Congruent but Malaligned

SurfacesSurfacesCartilage narrowing or Cartilage narrowing or

incongruity or both incongruity or both

Prognosis if Prognosis if

untreateduntreatedPoor Poor Poor Poor

DIFFERENCE

PAUWEL’S VARUS OSTEOTOMY

Varus intertrochanteric femoral osteotomies are designed 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°

Oblique cut is made parallel to the chisel inserted

Proximal fragment is rotated in varus .

Wedge being shifted to lateral side.

FINAL RESULT

Insertion of angled blade plate

TYPES OF WEDGE IN VARUS OSTEOTOMY

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

Valgus intertrochanteric femoral osteotomies 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 :-

Pelvic Osteotomies

Reconstructive Salter 18m – 6y Pemberton18m – 10y Steel skeletal maturity PAO (Ganz) skeletal maturity

Salvage Chiari skeletal maturity

SALTER'S INNOMINATE OSTEOTOMY

In this, the entire acetabulum together with pubis and ischium is rotated as a unit.

INDICATIONS: CDH in children from 18 months to 9 years of age and in

congenital subluxation upto early adult life.

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.

Osteotomy made from AIIS to Greater Sciatic

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.

anteriorlyanteriorly

Secure it by passing a K-

wire from proximal

fragment through graft

into distal fragment taking

care not to enter

acetabulum.

Subluxation in DDH After SALTERS osteotomy

ADVANTAGES: Relatively simple procedure. No change in acetabular configuration.

DISADVANTAGES: Relatively unstable needs internal fixation. Second surgery for pin removal. Possibility of joint penetration by pins.

PEMBERTON ACETABULOPLASTY

This operation redirects the inclination of the acetabular roof by an osteotomy of the ilium, superior to the acetabulum followed by levering of the roof inferiorly.

INDICATION:

In dysplastic hips between the age of 1 year and the age when the tri-radiate cartilage became too inflexible to serve as a hinge (about 12 years in girls and 14 years in boys).

First cut is made from the outer cortex of the ilium,

starting just above the AIIS and extending backwards till it

reachestriradiate cartilage.

A similar cut is made in the medial cortex directing it posteriorly, parallel with the previous one until it reaches the triradiate cartilage.

With a wide curved osteotome lever the distal

fragment distally until anterior edges of two

fragments is at least 2-3cm apart.

Resect a wedge of bone from anterior part of ilium including ASIS. Place the wedge of bone in the groove made and drive

the wedge into place and impact it.

ADVANTAGES: 1. Osteotomy is incomplete, therefore more stable

2. Internal fixation is not required

3. Greater degree of correction can be achieved with less rotation of the acetabulum.

DISADVANTAGES: 1. Technically more difficult

2. It alters the configuration and capacity of the acetabulum and can result in an incongruence relationship between it and femoral head.

Acetabular dysplasia after treatment of CDH with Pemberton acetabuloplasty on Right side.

TRIPLE INNOMINATE OSTEOTOMY BY STEEL

INDICATIONS- :-

Adolescents & skeletally mature adults with residual dysplasia &

subluxation in whom remodelling of acetabulum is no

longer anticipated.

ADVANTAGE –

Better coverage of femoral head by articular cartilage , Better hip joint stability, no need of spica

cast.

1

2

3

1.Osteotomy made from AIIS to Greater Sciatic

notch

2. Ischial ramus is

divided

posterolaterally at 45°

from perpendicular.

3.Superior pubic ramus is divided

posteromedially 15° from perpendicular.

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.

MODIFIED BY LIPTON & BOWEN1. Resecting 1-1.5 cm bone from ischial tuberosity to favor

medialization.2. To resect a triangular wedge from outer part of ilium

which favors slot formation which serves as abutment.3. Use 7.3mm cannulated screws instead of steinmann

pins.

SHELF OSTEOTOMY BY STAHELI

Have commonly been performed to enlarge the volume of the acetabulum.

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

Best to do after 5 years of age.

CE Angle is measured in standing AP radiograph.

After packing the graft the rectus femoris is sutured for stability of the graft .

Postoperative: hip spica can be applied in 15 deg of abduction and 20° of flexion.

Pre operative post op

CONTRA-INDICATIONS:

1. DDH with spherical congruity suited for re-directional osteotomy.

2. Hips requiring concurrent open reduction that must have supplementary stability.

3. Patients un-suited for spica cast application.

CHIARI OSTEOTOMY

This is a capsular interposition osteotomy as the capsule is interposed between the newly

formed acetabular roof and femoral head.

INDICATIONS:1. Congenital subluxation in patients 4 to 6 years

or older, including adults. 2. Dysplastic hip with osteoarthritis3. For Coxa magna after Perthes disease or

avascular necrosis after treatment of congenital dysplasia.

4. For paralytic dislocation caused by muscular weakness or spasticity.

TECHNIQUE :ANT-LAT APPROACH

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 20° 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.

PRE OP POST OP WITH CHIARI

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.

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

PAUWEL'S `Y' OSTEOTOMY

A guide pin is inserted from the greater trochanter to head of femur.

One limb of osteotomy is made from the base of greater trochanter towards the base of neck medially and inferiorly.

The distal limb of the Y then passes upwards and medially to reach the proximal limb and a wedge of bone with the required correction is removed from the proximal aspect of distal fragment with its base directed laterally.

The trochanter head segment is levered into valgus.

The two fragments are apposed by displacing the proximal end of the shaft medially and abducting the limb.

The nail is then attached by a plate to the shaft.

SUGIOKA TRANSTROCHANTRIC ROTATIONAL OST.

This is done for osteonecrosis to prevent progressive collapse of the articular surface and to improve the congruity of hip joint.

To do this the femoral head and neck segment is rotated anteriorly around its longitudinal axis, though a trans-trochantric osteotomy.

So that the weight bearing force is transmitted to the posterior articular surface of femoral head, which is not involved in the ischemic process.

Through lateral approach expose the capsule, osteotomize the greater trochanter.

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

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

femoral artery at inferior edge of Quadratus femoris

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

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