OSTEOTOMIES AROUND

THE HIP

Presented by : Moderator :

Dr. Hemant kumar pippal Dr. Mudasir malik

1

DEPARTMENT OF ORTHOPAEDIC

SUREGERY

MAULANA AZAD MEDICAL COLLEGE

AND LOK NAYAK HOSPITAL

3/10/2013

What is osteotomy? 2

An osteotomy is a surgical corrective

procedure done 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.

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Valgus osteotomy

Ganz osteotomy

How does osteotomy work?4

Increases the contact area / congruency

Improves coverage of the femoral head.

Moves normal articular cartilage into weight

bearing zone.

Restores biomechanical alignment.

Promotes cartilage regeneration(doubtful)??

Biomechanics of the hip5

Ratio of lever arms

3:1

Classification of osteotomies

around hip6

Pelvic Osteotomy

Reorientation Osteotomies : eg. Single,

Double, Triple Innominate, Periacetabular,

spherical

Salvage Osteotomies : eg. Chiari, Shelf

Femoral Osteotomy

Transcervical

Intertrochanteric Osteotomy

Subtrochanteric Osteotomy

Pelvic osteotomies 7

Commonly employed in developmental

dysplasia of the hip, leading to a shallow

acteabular cavity and subluxed or dislocated

joint.

Early reports stated that, acetabular

development was completed by 18 months of

age, others have found that acetabulum

develops till 8 yrs, if reduced before 4 yrs of

age.

There is a good evidence if significant dysplasia

persists at 5 yrs of age, an osteotomy should

be performed.

Osteotomy at work8

Pemberton osteotomy

Pelvic osteotomies9

Reorientation procedure

Pemberton

Salter

Steel

Dega

Ganz

Tonnis

Spherical/dial osteotomies

Wagner/ Eppright

Ninomiya

Salvage procedure

Chiari

Shelf

CENTER EDGE ANGLE &

ACETABULAR INDEX

CE ANGLE-measured after 5 yr age, >25 normal,

<20 severe dysplasia

AC IND- <27.5 normal, >30 dysplasia

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Pemberton osteotomy11

PROCEDURE- Pemberton described a pericapsularosteotomy of the ilium in which the osteotomy ismade through the full thickness of the bone fromjust superior to the anteroinferior iliac spineanteriorly to the triradiate cartilage posteriorly. Thetriradiate cartilage acts as a hinge on which theacetabular roof is rotated anteriorly and laterally.

INDICATION: In dysplastic hips between the age of18 months and 6 yrs, the age when triradiatecartilage becomes too inflexible.

>10-15 degrees correction of acetabular indexrequired.

Small femoral head ,large acetabulum.

12 Medial cut inferior to the level of the outer cut

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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, if its

larger

3. Premature closer of triradiate cartilage.

Salter innominate osteotomy15

INDICATIONS:

<10-15 degrees correction of acetabular index required.

DDH, paralytic disorder, subluxation after septic arthritis

PREREQUISITES-

the hip should be concentrically reduceable.

Contracture of iliopsoas and adductor muscles must be

released,

range of motion of the hip must be good specially in

abduction internal rotation, flexion.

AGE- 2-9years

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17

18

19

20

21

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Advantages

No affect on acetabular capacity

Technically less demanding

Complications

Neurovasulcar bundle damage

lateral femoral cutaneous

sciatic, femoral, obturator nerve

nutrient vessels to tensor fasciae lata.

Faulty positioning of pins can happen.

TRIPLE INNOMINATE OSTEOTOMY BY

STEEL25

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.

DISADVANTAGE- Technically

difficuilt, does not change size of

acetabulum, distort the hip such

that natural child birth may be

impossible in adulthood

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3

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27

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1.Osteotomy made from

AIIS to Greater Sciatic

notch

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Steel osteotomy30

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Immediate post op in 16yr old girl

After 1 yr of STEEL osteotomy

GANZ (BERNESE) PRIACETUBULAR

OSTEOTOMY.32

This Triplaner osteotomy is 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.

Ganz osteotomy33

GANZ OSTEOTOMY34

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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.

Spherical osteotomy36

Ninomiya osteotomy

CHIARI OSTEOTOMY37

PROC-It is performed at the superior margin of the

acetabulum ,where capsule of hip joint ends, and

acetabulum is pushed medially along, length of iliac

bone

This is also called as capsular interposition

Arthroplasty as the capsule is interposed between

the shelf and the femoral head.

INDI-incongruous joint, dysplastic hip with

osteoarthritis other osteotomy not possible

DISADV-salvage osteotomy only, leaves anterior

acetabulum uncovered, abductor lurch common .

Chiari osteotomy

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Chiari xray39

Chiari40

Komal, 17 yr female

SHELF OPERATION (STAHELI)

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Have commonly been performed to enlarge thevolume of the acetabulum.

The objective is to create a shelf, the size of which isdecided by measuring the “width of augmentation”form the CE angle. Normally around 35 degrees

Best to do after 5 years of age.

Indication : A deficient acetabulum that cannot becorrected by reorientation osteotomy is the primaryindication.

Contraindication :

Dysplastic hip with spherical congruity suitable forreorientational osteotomy

Hip requiring open reduction.

Shelf procedure42

Width of

augmentation to be

calculated from

centre edge angle

Objective is to

achieve a normal

centre edge angle

of 35 degrees.

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Pre operative 1 yr post op

OVERVIEW OF PELVIC

OSTEOTOMY44

Review of pelvic osteotomy45

Femoral osteotomy46

Technically can be of four types only

Lineal

Torsional/derotation

Trans positional

Angulation

adductional/varus

abductional/valgus

Lineal osteotomy47

Can be done after skeletal

maturity has been achieved

Usually done to correct limb

length disparities.

Maximum lengthening 2-3

inches

Shortening 4-5 inches.

Torsional/ derotation osteotomy48

Altering the angular

relationship of femur neck

and bicondylar axis

Important to differentiate

between rotation and torsion.

Transpositional osteotomies49

Longitudinal axis of the distal

fragment is parallel to

longitudinal axis of proximal

Almost invariably, only medial

displacement is done

Putti osteotomy

Mcmurray osteotomy

McMurray osteotomy50

Oblique osteotomy extends from the lateral

aspect of the shaft at a level just below the lower

border of the lesser trochanter and lower border

of neck.

Fixation by blade plate, spline may be required.

INDICATIONS: Nonunion of femoral neck

Advanced osteoarthritis .

AIM : Mechanical axis shifted medially

Shearing force at the nonunion is decreased,because the fracture surface has become morehorizontal

McMurray osteotomy51

Disadvantages:

Instability - Degenerativechanges in normal head

Shortening - AVN whenneck have been fractured

Medial displacement ofshaft compromise theinsertion of femoral stemof total hip.

Advantage -Changes line offracture to horizontal, callusmay incorporate fracture

Angulational osteotomies52

Mechanical axis along with

relationship of articular surfaces

at the opposite end of the bone

is also altered

shortening of the effective length

of the bone, which is maximal ,

at center.

Osteotomy should ideally be

performed at the site of deformity

itself.

Angulational osteotomies53

Angulational osteotomies54

Basic principles of ostetotomy55

Angulational ostotomies56

Femur, when viewed from side, straight in anteropostrior, bent at intertrochantric line to produce femoral neck….

Effectively, in abduction, the shortening resulting from angulation is offset by increase in effective length till the head of the femur lies in extended longitudnal axis of distal fragment.

Adductional / varus osteotomy 57

May be performed at intertrochantric or

subtrochantric levels

Indications

Correction of abductional malalignments

Broomstick femur( sequale of osteomyelitis)

Congenital hip dislocations

Hip osteoarthritis ???? Mechanism unclear

Length discripancies

Free abduction and adduction should be

possible in all angulation osteotomies.

Varus osteotomy

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VARUS OSTEOTOMIES

Varus osteotomy

Designed to elevate the greater trochanter and move it

laterally while moving the abductor and psoas muscles

medially, to restore joint congruity and decrease muscle

forces about the hip.

Varus osteotomy alone is indicated for patients with a

spherical femoral head, little or no acetabular dysplasia

center-edge angle of at least 15 to 20 degrees), signs

lateral overloading, and a valgus neck-shaft angle of

more than 135 degrees.

Varus osteotomy with medial displacement of the femoral

shaft relaxes the abductor, psoas, and adductor muscles

unloads the hip joint, and increases the weight-bearing

surface.

Most authors recommend medial displacement of 10 to

15 mm to keep the ipsilateral knee centered under the

femoral head and to maintain the mechanical axis of the

leg.

Varus osteotomy, however, shortens the limb to some

degree. creates a Trendelenburg gait that may persist for

months after surgery, and increases the prominence of

the greater trochanter.

Limb shortening can be minimized by making a smaller

medial osteotomy and transposing it to the lateral side.

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Abductional/valgus/pelvic support

osteotomy68

Distal osteotomised fragment is tilted away

from midline, increasing the femoral neck

angle

Abductional ostetomy when anatomical axis

comes medially and mechanical axis comes

laterally

At a point it touches ischial tuberosity, acting

now as pelvic support osteotomy.

lorenz bifurcation osteotomy

Schanz osteotomy

Valgus osteotomy73

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Lorenz bifurcation osteotomy75

Described for congenital dislocation of hip

In this upper end of the osteotomised fragment is

abducted and inserted in to the acetabulum or make

contact with ischium forming a spike with or without

intertrochanteric osteotomy.

Disadvantage :

Increased shortening.

Less mobility and arthritic pain.

Peculiar waddling gait, adduction restriction

Lorenz bifurcation osteotomy76

Schanz osteotomy77

Schanz osteotomy

Similar to lorenz ostetotomy, but no spike is made assuch, ostetomised fragments do not make conatctwith ischium.

Preparation :X-ray are taken with full adduction – to measure

angle medially. Thomas Test - measure degree of flexion to be

corrected.

Advantages : Lurching gait will be diminished. The depression of the trochanter also improves the

leverage of the glutei.Better adduction as compared to lorenz, and no

arthritc pain

Schanz osteotomy78

Postosteotomy angle79

Apart from the degree of abduction, many

factors affect the lateralisation of mechanical

axis; namely site of osteotomy and previuosly

present femoral neck angle

It has been defined as the angle formed

between, line drawn along inner aspect of

cortex of distal fragment, and oblique

linedrwan from upper end of distal fragment to

most medial part of proximal fragment.

Considered as neck angle of osteotomised

femur

Postosteotomy angle80

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