Pemberton's Osteotomy for Acetabular Dysplasia

PEMBERTON OSTEOTOMY FOR ACETABULAR DYSPLASIA

JBJS- ESSENTIAL SURGICAL TECHNIQUESINDIAN EDITION

OCTOBER 2015, VOL.4, NO. 3, SPECIAL EDITION

Shier- Chieg Huang, MD, PhDTing- Ming Wang, MD, PhD

Kuan- Wen Wu, MDKen N. Kuo, MD

PRESENTED BY Dr. LIBIN THOMAS MANATHARA

INTRODUCTION• More than 550 operations of Pemberton's osteotomy

done as primary treatment for developmental dysplasia of hip since 1993

• Originally described by Pemberton in 1965• Pericapsular Osteotomy of the Ilium for Treatment of Congenital

Subluxation and Dislocation of the Hip, PAUL A. PEMBERTON, J Bone Joint Surg Am, 1965 Jan; 47 (1): 65 -86 . http://dx.doi.org/

INTRODUCTION

• Characterised by a redirection of the acetabular roof, hinged on the triradiate cartilage after an incomplete iliac osteotomy

INTRODUCTION

• The shape of the acetabulum is modified by rotating the acetabular fragment caudally and anteriorly to improve the anterior and lateral coverage of the femoral head

• Two similar modifications, the Dega osteotomy and the San Diego osteotomy were designed for the same purpose

INTRODUCTION• With the Dega, the osteotomy penetrates

the anterior and middle portions of the inner cortex of the ilium and leaves an intact posteromedial iliac cortex and sciatic notch as a posterior hinge

• The San Diego utilises complete bicortical osteotomies both anteriorly and posteriorly, to provide increased superior and posterior coverage

https://books.google.co.in/books?id=lWV47ye7jTUC&pg=PA137&lpg=PA137&dq=san+diego+osteotomy&source=bl&ots=3QDqfnpxiq&sig=a4tfFaimCgj8HEs9Ubt1bsNE_1I&hl=en&sa=X&ved=0ahUKEwj--aLn7s7JAhVGTBQKHZfHDNYQ6AEILjAC#v=onepage&q=san%20diego%20osteotomy&f=false

http://hipdysplasia.org/developmental-dysplasia-of-the-hip/child-treatment-methods/osteotomy/

INTRODUCTION• Most experienced pediatric orthopedic surgeons can

expect the Pemberton acetabuloplasty to yield greater correction of acetabular dysplasia than the Salter innonimate osteotomy , without the need for internal fixation of the osteotomy site

• Salter innonimate osteotomy- a type of open wedge innominate osteotomy which extends and retroverts acetabulum around fixed axis, it redirects entire acetabulum so that its roof covers femoral head both anteriorly and superiorly, it extends and retroverts acetabulum around fixed axis

INTRODUCTION• Although some authors have cautioned

against the use of the Pemberton osteotomy in children older than 7yrs because of concerns about decreasing remodeling potential and a less flexible triradiate cartilage, some investigators have reported that the Pemberton osteotomy can be done at a later age with good results, when combined with a proximal femoral osteotomy

INTRODUCTION

• Nevertheless the iatrogenic injury to the triradiate cartilage resulting from an incorrectly performed Pemberton's osteotomy is a possible serious complication which may cause premature closure of the triradiate cartilage resulting in a shallow acetabulum

STEPS

• 1) Exposure• 2) Perform iliopsoas tenotomy• 3) Perform open reduction and osteotomy• 4) Insert iliac bone graft• 5) Postoperative management

STEP 1- EXPOSURE

• Place the patient in supine position with a towel roll under the buttock and chest on the side on which the operation is to be performed

• Make an anterior iliofemoral incision that is not directly on the iliac crest

https://www2.aofoundation.org/wps/portal/surgery?showPage=preparation&contentUrl=srg/32/03-Preparation/32_P3_supine.jsp&bone=Femur&segment=Shaft&preparation=Supine%20position%20without%20traction&Language=en

An anterior iliofemoral incision is used, caudal to the anterior superior iliac spine (ink outline to the right of the incision line mark) and the iliac crest.

Shier-Chieg Huang et al. JBJS Essent Surg Tech 2011;1:e2

©2011 by The Journal of Bone and Joint Surgery, Inc.

https://www2.aofoundation.org/wps/portal/!ut/p/a0/04_Sj9CPykssy0xPLMnMz0vMAfGjzOKN_A0M3D2DDbz9_UMMDRyDXQ3dw9wMDAzMjfULsh0VAbWjLW0!/?approach=Iliofemoral%20approach&bone=Femur&classification=31-C1&implantstype=&method=&redfix_url=&segment=Proximal&showPage=approach&treatment=&contentUrl=/srg/31/04-Approaches/2008/31_Nr50_Appr_Iliofemoral.jsp ANTERIOR APPROACH (Iliofemoral or Smith-Peterson)

Exposure

• Dissect the subcutaneous tissue• Identify the muscle interval between

Sartorious and Tensor Fascia Lata (TFL)• In this intermuscular interval, beneath the

deep fascia you can find the fatty tissue around the lateral femoral cutaneous nerve (LFCN)

http://www.jointpreservationinstitute.com/hip-dysplasia.html

https://www.pinterest.com/pin/458241330809772070/


Exposure

• Incise this deep fascia carefully• Identify the nerve clearly and protect it with

gentle traction• Retract it medially after it is well mobilised

both proximally and distally

http://www.healio.com/orthopedics/journals/ortho/2015-7-38-7/%7B74701f36-0fe6-4c77-a834-dde1e99e9c58%7D/hybrid-anterolateral-approach-for-open-reduction-and-internal-fixation-of-femoral-neck-fractures

"Gray826-LFC" by Dan Hoey - Edited version of PD image Image:Gray826.png. Licensed under Public Domain via Commons - https://commons.wikimedia.org/wiki/File:Gray826-LFC.png#/media/File:Gray826-LFC.png

http://thepainsource.com/meralgia-paresthetica-lateral-femoral-cutaneous-neuropathy/

Exposure

• Expose the iliac crest• Releasing the external oblique muscles on

the crest facilitates the exposure of the cartilagenous iliac apophysis

• Identify the anterior superior iliac spine (ASIS)

http://ranzcrpart1.wikia.com/wiki/Abdomen:Muscles:Anterolateral_abdominal_muscles_and_aponeuroses

http://orthopaedicprinciples.com/2013/06/idiopathic-scoliosis-rishi-m-kanna/

Exposure

• Divide the cartilage at the iliac crest by identifying it with thumb and index finger and incising directly in the midline

• Strip off each half of the iliac apophysis with a periosteal elevator to expose the ilium subperiosteally both medially and laterally

The iliac crest cartilaginous apophysis is split sharply, with the thumb and the index finger used to gauge the thickness and direction of the iliac wing.



Exposure

• Pack a gauze sponge on the inner and outer cortices to facilitate subperiosteal dissection and provide hemostasis

• Expose the anterior inferior iliac spine (AIIS) by elevating the periosteum with the hip abductor muscles from the outer cortex of the ilium until the AIIS is clearly defined

http://slideplayer.com/slide/4207487/

https://www.studyblue.com/notes/note/n/pelvic-appendage-features-identification/deck/14579134

http://posterng.netkey.at/ranzcr/viewing/index.php?module=viewing_poster&task=viewsection&pi=119180&ti=391135&searchkey= AVULSION FRACTURE OF THE LEFT AIIS

http://www.anatomy-physiotherapy.com/component/content/article?id=1070:differentiated-activation-of-hip-abductors

http://bodybuilding-wizard.com/muscles-that-act-on-the-hip/

STEP 2- PERFORM ILIOPSOAS TENOTOMY

• Identify the tendon of the straight head of the rectus femoris at its origin on the AIIS

• Transect the tendon close to the AIIS but leave a short stump for later tendon reattachment

http://www.anatomy-physiotherapy.com/27-systems/musculoskeletal/lower-extremity/hip/1055-origin-of-the-direct-and-reflected-rectus-femoris-head

from Arthroscopy. 2014 Jul;30(7):796-802. doi: 10.1016/j.arthro.2014.03.003. Epub 2014 May 2.Origin of the direct and reflected head of the rectus femoris: an anatomic study.Ryan JM1, Harris JD2, Graham WC1, Virk SS1, Ellis TJ3

http://www.ncbi.nlm.nih.gov/pubmed/?term=Origin+of+the+Direct+and+Reflected+Head+of+the+Rectus+Femoris:+An+Anatomic+Study

http://radsource.us/rectus-femoris-quadriceps-injury/

The tendon of the straight head of the rectus femoris muscle is isolated and is divided just caudal to the anterior inferior iliac spine (AIIS).



PERFORM ILIOPSOAS TENOTOMY

• Protect and preserve the ascending branch of the anterior/ lateral femoral circumflex artery (LFCA), which may be visible in the surgical field at this time

"Thigh arteries schema" by Human_leg_bones_labeled.svg: Original uploader was Jecowa at en.wikipediaderivative work: Mcstrother (talk) - Human_leg_bones_labeled.svg. Licensed under CC BY 3.0 via Commons - https://commons.wikimedia.org/wiki/File:Thigh_arteries_schema.svg#/media/File:Thigh_arteries_schema.svg

http://scientia.wikispaces.com/thigh+and+leg+-+lecture+notes


• Bluntly dissect the iliacus muscle belly medial to the ilium and identify the psoas tendon at the level of the anterior pelvic rim

• Release the tendinous part of the iliopsoas muscle

http://www.stretchify.com/psoasiliopsoas-stretches/

The iliopsoas tendon is identified at the pelvic rim, and the tendinous portion is divided, leaving the muscular portion intact.




• Be careful of the femoral neurovascular bundle, which is located immediately medial to the psoas muscle but on the anterior aspect

• The femoral NV bundle can be retracted and protected with a blunt retractor

http://accessmedicine.mhmedical.com/data/books/mort/mort_c036f003.gif


• Identify the acetabulum- hip capsule junction • If the femoral head is well reduced in the

acetabulum, you can identify the edge of the acetabulum and the reflected head of the rectus femoris mucle easily

• Dissect the soft tissue overlying the capsule and then identify the margin of the joint capsule at the acetabular rim

http://www.americanhipinstitute.org/wp-content/themes/american-hip-institue/images/psoas-impingement.jpg

http://jbjs.org/content/96/20/1673


• Sometimes the capsule becomes redundant and adherent to the ilium as the result of a previous femoral head dislocation

• In this situation, dissect the abductor muscle from the capsule and use a periosteal elevator to strip off any soft tissue from the anterior aspect of the ilium to reveal the junction of the hip capsule and cartilagenous labrum

http://helpmegrowutah.blogspot.in/2013/03/hip-healthy-swaddling-developmental.html

http://orthoinfo.aaos.org/topic.cfm?topic=a00347

STEP 3- PERFORM OPEN REDUCTION AND OSTEOTOMY

• Perform an open reduction• If the femoral head is dislocated, perform a

T- shaped capsulotomy near the acetabular rim, including the upper and lower margins of the hip capsule

https://www2.aofoundation.org/wps/portal/!ut/p/a0/04_Sj9CPykssy0xPLMnMz0vMAfGjzOKN_A0M3D2DDbz9_UMMDRyDXQ3dw9wMDAzMjfULsh0VAbWjLW0!/?approach=Iliofemoral%20approach&bone=Femur&classification=31-C1&implantstype=&method=&redfix_url=&segment=Proximal&showPage=approach&treatment=&contentUrl=/srg/31/04-Approaches/2008/31_Nr50_Appr_Iliofemoral.jsp

Capsular incision outline with the stem of the T parallel with the femoral neck.



PERFORM OPEN REDUCTION AND OSTEOTOMY

• Make the stem of the T- shaped capsulotomy parallel to the femoral neck, slightly superiorly to avoid a small inferior capsular flap, which will make the capsulorrhaphy more difficult

https://www2.aofoundation.org/wps/portal/surgery?showPage=approach&contentUrl=srg/31/04-Approaches/2008/31_Nr30_Appr_anterolateral.jsp&bone=Femur&segment=Proximal&approach=Anterolateral%20approach&Language=en


• Remove the ligamentum teres sharply and remove all of the fibrofatty tissue (pulvinar tissue) from the true acetabulum

• Identify and palpate the tension of the transverse acetabular ligament with your finger before releasing it with scissors

http://www.slideshare.net/hungnguyenthien/developmental-dysplasia-of-the-hip-and-ultrasound

http://boneandspine.com/hip-joint-anatomy/

https://www.studyblue.com/notes/note/n/joints-of-lower-limb-meszaros/deck/5355224


• Recheck to ensure that there is no tension of the transverse acetabular ligament after release, as remaining transverse acetabular ligament can impede complete reduction of the femoral head


• Check hip stability • Reduce the femoral head into the

acetabulum under direct vision and test the hip stability in a neutral position as well as in abduction and internal rotation


• If the hip is unstable in a neutral position but is stable in abduction and internal rotation, a Pemberton acetabuloplasty is indicated

• If hip stability cannot be maintained even in abduction and internal rotation, an additional proximal femoral varus and/ or rotational osteotomy should be considered

Varus osteotomy of the femurOpen Reduction, Pelvic Osteotomy, Femoral Shortening and Varus Osteotomy -

See more at: http://hipdysplasia.org/developmental-dysplasia-of-the-hip/child-treatment-methods/osteotomy/#sthash.BArftDsO.dpuf


http://kbird.com/2010/12/hip-dysplasia-repair-illustrations/


• Make medial and lateral cut lines• Remove the gauze sponge on either side

of the iliac bone• Check bleeding from perforating vessels

from the iliac wing


• Once hemostasis is achieved, you can proceed with the Pemberton osteotomy

• Locate the sciatic notch first with a small periosteal elevator and protect the adjacent soft tissue, including the sciatic nerve, with a retractor


• Begin with the medial iliac cut first• Outline the cut line with the electrocautery

tip• Using a small straight osteotome, begin

the medial cut line about 1 to 1.5cm above the superior hip joint line and curve it inferiorly and posteriorly, aiming at the sciatic notch

Medial cut line: outline on a skeletal model.



Medial cut line: outline on a reconstructed three-dimensional computed tomography (CT) scan.



Medial cut line in the surgical field.




• The cut line extends halfway to the sciatic notch and ends at the ridge of the pelvic inlet of the ilium

• The lateral cut line has the same starting point as the medial cut

• With the medial cut line as a reference, use the same osteotome to make the lateral cut line along the joint capsule

Lateral cut line: outline on a skeletal model.



Lateral cut line: outline on a reconstructed three-dimensional computed tomography (CT) scan.



Lateral cut line in the surgical field.




• Complete the osteotomy• Use wider curved osteotomes to complete

the osteotomy, beginning anteriorly and following the medial and lateral cut lines

• As this osteotomy advances, push the osteotome against the distal fragment to check the degree of downward displacement

Iliac osteotomy with use of a large curved osteotome.



http://teachmeanatomy.info/pelvis/bones/pelvic-girdle/hip-bone-of-a-5-year-old-triradiate-cartilage-present/


• If the osteotomy site opens more than 2 to 3cm and the distal fragment hinges on the triradiate cartilage, there is no need to further advance the osteotome

• If the opening is insufficient, advance the osteotome and check the amount of osteotomy opening again

STEP 4- INSERT ILIAC BONE GRAFT

• Harvest a wedge shaped iliac crest bone graft (about a 35 degree wedge) from the iliac wing

• Reduce the femoral head and place a towel roll under the knee to help maintain the hip in an abducted and flexed position

INSERT ILIAC BONE GRAFT

• Hold the inferior osteotomy fragment open anteriorly and inferiorly with a towel clip to cover the femoral head

• Then insert the triangularly shaped bone graft into the osteotomy opening site


• Usually, the osteotomy bone fragment is stable and there is no need for internal fixation

• If the bone graft is not stable, fixation with one or two Kirschner wires may be necessary

Surgical field in which a bone graft is maintaining the opening of the osteotomy site.



Postoperative reconstructed three-dimensional computed tomography (CT) scan from the anterior view showing the bone graft in place.



Postoperative reconstructed three-dimensional computed tomography (CT) scan from the posterior view showing the bone graft in place.



http://clinicalgate.com/pediatric-pelvic-osteotomies-and-shelf-procedures/


• Repair the hip capsule by bringing the two flaps of the T- capsulotomy to the acetabular flap of the capsule

• It is not necessary to resect the redundant capsule

https://www2.aofoundation.org/wps/portal/!ut/p/a0/04_Sj9CPykssy0xPLMnMz0vMAfGjzOKN_A0M3D2DDbz9_UMMDRyDXQ3dw9wMDAzMjfULsh0VAbWjLW0!/?approach=Anterolateral%20approach&bone=Femur&segment=Proximal&showPage=approach&contentUrl=/srg/31/04-Approaches/2008/31_Nr30_Appr_anterolateral.jsp


• Repair the tendon of the straight head of the rectus femoris muscle to the AIIS

• Suture the iliac apophysis over the remaining ilium and close the wound

STEP 5- POSTOPERATIVE MANAGEMENT

• Apply a hip spica cast after skin closure• An assistant should hold both hips in

about 20 degrees of flexion, 30 degrees of abduction and neutral or slight internal rotation while the cast is applied

• The spica cast is worn for four weeks after a simple Pemberton osteotomy

https://myhealth.alberta.ca/Health/Pages/conditions.aspx?hwid=hw165967

POSTOPERATIVE MANAGEMENT

• If a combined open hip reduction procedure was done, the hip spica cast is used for 6 weeks, this is followed by use of 4 weeks of a hip abduction brace or a bilateral cylinder cast with a spreader bar to hold the hips in 60 degrees of abduction (30 degrees of abduction for each hip)

http://www.aposortho.com/hip-child-apos.html

RESULTS

• In their clinical and radiological review of 49 patients followed up for more than 10years after treatment of DDH of hip with a unilateral PO, there were no redislocations and no patient required additional surgery for residual hip dysplasia after the original PO

RESULTS

• If there was overcorrection or inferior displacement of the reduced femoral head , there was a high risk of femoral head osteonecrosis

• X rays of a patient treated at 20months and followed up for 14yrs after the surgery are shown

Anteroposterior pelvic radiograph of a twenty-month-old girl with developmental dysplasia of the left hip.



Immediate postoperative anteroposterior radiograph showing the reduced hip after the Pemberton osteotomy.



When the patient was fifteen years old, the left hip had an excellent result.



INDICATIONS• Developmental dysplasia of the hip• Acetabular dysplasia• Legg- Calve- Perthe's disease with

femoral head subluxation/ lateral protrusion

• Anterosuperior deficiency of the acetabulum secondary to neuromuscular disease

• Sequelae of an infected hip with femoral head subluxation

CONTRAINDICATIONS

• Closed triradiate cartilage• Deformed femoral head• Small acetabular volume• Active infection/ Osteomyelitis

PITFALLS AND CHALLENGES

• Bone graft dislodgement• Overcorrection may cause femoral head

impingement and osteonecrosis• Premature triradiate cartilage closure• Transiliac lengthening of the ipsilateral

limb at the time of the opening wedge osteotomy

THANK YOU

Pemberton's Osteotomy for Acetabular Dysplasia

Health & Medicine

Transcript of Pemberton's Osteotomy for Acetabular Dysplasia