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osteotomies around hip by dr gandhiPresentation Transcript
OSTEOTOMIES AROUND HIP
DEPARTMENT OF ORTHOPAEDICS & TRAUMATOLOGY GANDHI MEDICAL COLLEGE, BHOPAL PRESENTED BY : Dr. Vaibhav Gandhi MODERATOR : Dr. A. Gohiya Dr. S. Tandon CONSULTANTS : Prof. & HOD Dr. N. Shrivastava Prof.Dr. A. Mehrotra Dr. S. Gaur Dr. J. Shukla Dr. S. Tandon Dr. S. A. Faruqui Dr. A Gohiya Dr. A. Varshney Dr. D. Maravi Dr. R. Verma Dr. A. Pathak
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.
Improving abductor function will decrease joint reaction forces
As the ratio of length of the lever arm of body weight to that of the abductor musculature is @ 2.5:1,the force of abductor muscle must approx 2.5 times the body weight to maintain the pelvis level when standing on one leg
In an arthritic hip , the ratio of lever arm of the body weight to that of the abductors may be 4:1.
The length of two lever arms can be surgically changed to make their ratio 1:1
OSTEOTOMY AROUND HIP CLASSIFICATION
According to Anatomic Location
Salvage Osteotomies : eg. Chiari, Shelf.
Reconstructive Osteotomies : eg. Periacetabular, Single, Double, Triple Innominate.
Based on Indications
To obtain stability
old unreduced dislocations.
Lorenz bifurcation osteotomy.
Schanz low subtrochanteric.
To obtain union
ununited fractures of femoral neck.
Dickson's high geometric osteotomy.
Schanz Angulation Osteotomy.
unstable intertrochanteric fractures.
Dimon Hughston Osteotomy.
Relief of pain
Pauwel’s type I varus osteotomy.
Pauwel’s type II valgus osteotomy.
To Correct deformities
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).
In Osteonecrosis of femoral head
Sugioka’s transtrochanteric osteotomy.
Varus deroation osteotomy of Axer.
- In paralytic disorders of hip.
In congenital dislocation.
OVERVIEW OF PELVIC OSTEOTOMY
INDI -Congruous hip reduction,<10-15 degrees correction of acetabular index required ,paralytic disorder,subluxation after septic arthritis
PREREQUISITES- femoral head must be positioned opposite the level of acetabulum,contracture of iliopsoas and adductor muscles must be released, range of motion of the hip must be good specially in abduction ,int rotation flexion
AGE- 18 months-6years
AFTERCARE- hip spica for 8 to 12 week,then partial weight bearing on crutches ,followed by full weight bearing.result assesed by center edge angle.
CASE -abdulla,2yr /m, B/L DDH, operated at GMC BHOPAL , O/D – SALTER osteotomy with k-wire fix with femoral shortening
PROCEDURE- Pemberton described a pericapsular osteotomy of the ilium in which the 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.
INDICATION- >10-15 degrees correction of acetabular index required ,small femoral head ,large acetabulum.
ADV- internal fixation not required .greater degree of rotation can be achieved with less rotation of acetabulum
DISADV- Technically more difficult . Alters the configuration and capacity of acetabulum and produce joint incongruity that requires remodeling
AGE- 18months- 10 yr
AFTERCARE- spica cast for 8 to 12 weeks
PEMBERTON PERICAPSULAR OSTEOTOMY
PERIACETABULAR OSTEOTOMY OF ILIUM (PEMBERTON)
TRIPLE INNOMINATE OSTEOTOMY (STEEL)
INDI- Adolescents and skeletally mature adults with residual dysplasia and subluxation in whom remodelling of acetabulum is no longer anticipated
ADV- Better coverage of femoral head by articular cartilage [chiari- fibrous cartilage], Better hip joint stability,no need of spica cast.
DIS- Technically difficuilt, does not change size of acetabulum, distort the hip such that natural child birth may be impossible in adulthood
PROC- The ischium, the sup pubic ramus and ilium superior to the acetabulum is reposition and stabilized by bone graft
GANZ OSTEOTOMY: (BERNESE) PRIACETUBULAR OSTEOTOMY.
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.
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.
THE SHELF PROCEDURE (STAHELI)
SHELF OPERATION (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” form the CE angle. The shelf is put just above the acetabular margin. It secure two layers of cancellous grafts bringing the reflected head of rectus femoris forward over the graft and suturing it in its original position.
Best to do after 5 years of age.
Indication : A deficient acetabulum that cannot be corrected by redirectional, osteotomy is the primary indication.
Dysplastic hip with spherical congruity suitable for redirectional osteotomy
Hip requiring open reduction.
CENTER EDGE ANGLE/ACETABULAR INDEX
CE ANGLE-measured after 5 yr age, >25 normal, <20 severe dysplasia
AC IND- <27.5 normal, >30 dysplasia
INNOMINATE OSTEOTOMY WITH MEDIAL DISPLACEMENT OF ACETABULUM (CHIARI)
PROC- It is performed at the superior margin of the acetabulum and the pelvis inferior to the osteotomy along with the femur is displaced medially.
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
Reserve for cases is which reduction is not possible by either open or closed reduction as in old unreduced congenital dislocation.
Designed to improve :
Control pain arising from lower back/hip.
REVIEW OF PELVIC OSTEOTOMIES
In surgical planning of an osteotomy, the most important task is to determine whether the patient is an appropriate candidate. Determining factors are the patient’s age, activities, goals, radiographic assessment, range of motion, and leg lengths and the status of the knee of same side.
Primary objective is deflection of wt. bearing by angulation of femur to bring the axis of the femoral shaft more in line with the direction of weight transmission.
The osteotomy performed are Angulation Osteotomy (Stabilizing osteotomy).
SCHANZ OSTEOTOMY (LOW S/T OSTEOTOMY)
Femur is sectioned transversely a lower border of pelvis.
Upper end is angled inward until it rest against side wall of pelvis.
Schanz osteotomy (Low S/T Osteotomy) :
In this osteotomy the deformity flexion, adduction & external Rotation is corrected by making the osteotomy at tuber ischii level.
X-ray are taken with full adduction – to measure angle medially.
Thomas Test - measure degree of flexion to be corrected.
Lurching gait will be diminished.
The depression of the trochanter also improves the leverage of the glutei.
Contraindication : Before 15 years of age, because loss of angulation during growth period.
Lorenz (Bifurcation osteotomy)
In this upper end of the lower fragment is abducted and inserted in to the acetabulum after making on intertrochanteric osteotomy “plane of osteotomy” below & outward to above & inward.
Less mobility and arthritic pain.
LORENZ (BIFURCATION OSTEOTOMY)
(A) Plane of osteotomy – Distal end at posterolateral aspect towards proximal end at anteromedial aspect.
(B) Limb is Abducted and extended so proximal end of distal fragment directed medially and anteriorly in acetabulum.
OSTEOTOMY FOR COXA VERA
The normal femoral neck shaft angle in infant is 120 0 to 140 0 , Reduction to a more acute angle constitute a coxa vara deformity.
The goal of treatment are
To promote ossification of the defect and correct varus deformity.
Indication for surgery :
Increasing coxa vara
Neck shaft angle less than 110°.
Painful unilateral or associated with leg length discrepancy
Hilgenreiner - epiphy seal angle of more than 60° .
Surgery performed are
Valgus Subtrochanteric Osteotomy or abduction osteotomy-with Internal Fixation.
A transverse osteotomy at about the level of lesser trochanter.
If necessary take a small lateral wedge to correct neck shaft angle to 135-150.
The surgery may be delayed till child is 4 to 5 year old to make internal fixation easier.
Alternative Method : Pauwels Y shaped osteotomy :
Static forces are converted from shearing to impacting forces
Viable femoral head.
Young vigorous patient.
Union is rapid.
Recurrence is less likely.
PAUWELS Y SHAPED OST
OSTEOTOMY FOR RELIEF OF PAIN IN OSTEOARTHRITIS
Before the onset of osteoarthritis, if normal or near normal function of the hip can be maintained, reconstructive osteotomy can prevent or delay the development of osteoarthritis; if mild or moderate osteoarthritis is present, a salvage osteotomy can improve function and delay the need for total hip Arthroplasty.
THERAPEUTIC INTERVENTION IN HIP DIEASE :RECONSTRUCTIVE VERSES SALVAGE OSTEOTOMY Factors Reconstructive Osteotomy Salvage Osteotomy Age Generally < 25 years Generally < 50 years (Some biological Plasticity Remains) Symptoms Minimal (Out Progressive) Moderate to Severe Motion Near Normal > 60 0 Flexion Function Near Normal Fair to Poor Pthoanatomy No Irreversible Changes Irreversible Changes Roentgenography Congruent but Malaligned Surfaces Cartilage narrowing or incongruity or both Prognosis if untreated Poor Poor
The goal of reconstructive osteotomies, femoral or pelvic, is to restore as nearly normal anatomy as possible, thus returning joint pressures and loading patterns to normal.
The goal of salvage osteotomies are to relieve pain and improve function enough to delay the need for total hip Arthroplasty, especially in active patients younger than 50 years of age.
Roentgenographic evaluation also should include a standing anteroposterior view and a “false profile” view.
VARUS/VALGUS/DEROTATION FEMORAL OSTEOTOMIES ARE -
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 musclesunloads 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.
VALGUS INTERTROCHANTERIC FEMORAL OSTEOTOMIES
Valgus Osteotomy - Increase weight bearing area of femur head.
It does not produce muscle relaxation.
Relaxation obtained by tenotomy of Iliopsos and adductor muscle.
Transfer the center of hip rotation medially from the superior aspect of the acetabulum to increase joint congruity and the weight-bearing area of the femoral head.
Osteotomy of the greater trochanter often is performed with valgus femoral osteotomy to move the greater trochanter laterally.
VALGUS INTERTROCHANTERIC FEMORAL OSTEOTOMIES :
Best result were obtained in patients younger than 40 years of age with unilateral involvement, good preoperative range of motion, and a mechanical (secondary) cause.
Unsatisfactory results occurred in patients with limited preoperative flexion, they cited preoperative flexion of less than 60 degrees as a relative contraindication to valgus osteotomy.
Most surgeons now advise that all osteotomies be fixed with rigid internal fixation, which offers several obvious advantages:
The fragments are maintained in proper position;
The danger of limitation of motion of the hip and knee is greatly decreased;
The patient can be allowed out of bed early; and
Pulmonary, urological, and other medical complications are decreased. A device frequently used for rigid internal fixation of intertrochanteric osteotomies is the ASIF, or right-angled, blade plate. Our experience with this device has been quite favorable.
Nonunion has been a troublesome complication after Osteotomy, and an incidence as high as 20% has been reported.
BLOUNT ABDUCTION OSTEOTOMY
Motion in adduction beyond adduction deformity
BLOUNT ADDUCTION OSTEOTOMY
Antalgic abductor limp
Motion in abduction beyond the abduction deformity
BIOMECHANICAL TREATMENT OF OSTEOARTHRITIS
Therapy must be directed at reducing joint loads. This may be by reducing the compressive forces directly or by increasing the weight- bearing area, and thereby reducing the load per unit area or ideally by combination of the two.
WHILE PERFORMING OSTEOTOMY
The distal cut must be perpendicular to the axis of the shaft fragment.
All cortical wages are taken form the proximal fragment to avoid loss of apposition when the distal fragment is rotated.
General contraindication of femoral osteotomies -
Inflamatory joint condition
Significant metabolic disease.
Severe degenerative joint disease.
OSTEOTOMY TO CORRECT UNSTABLE INTERTROCHANTERIC FRACTURES
OSTEOTOMY TO CORRECT UNSTABLE INTERTROCHANTERIC FRACTURES
Dimon and Hughston :
Described technique of Trochanteric osteotomy with valgus nailing and medial displacement to improve stability there techniques are occasionally useful in some extremely comminuted fractures.
Recent studies have indicated that anatomical reduction allow greater load shearing by bone than medial displacement osteotomy.
DIMON AND HUGHSTON METHOD OF INTERTROCHANTERIC OSTEOTOMY
SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)
Is a disorder in which there is a displacement of the capital femoral epiphysis form the metaphysis through the physeal plate.
By this head is placed in posterior & downward position in acetabulum.
The goal of treatment is
To prevent further displacement and
To promote closure of physeal plate.
The use of realignment procedure such as lntertrochameric, Subtrochanteric Osteotomy & osteotomies the around neck is in those situation in which restricted range of motion impairs function after plate physeal closure.
Principle of Osteotomy
There are basically three type of Deformity present in SCFE. These are-
Moderate Severe external rotation
SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)
The osteotomy to correct these deformities work at two sites.
Through the femoral neck (closing wedge osteotomy)
Through the trochanteric area.
EXTRACAPSULAR BASE OF NECK OSTEOTOMY
types of femoral neck osteotomy are -
The technique of Dunn - for severe chronic slip with open physis.
Base of the neck osteotomy - Compensatory Basilar most of femoral neck. (Kramer) - correct the varus and retroversion component of moderate to severe chronic SCFE.
It is safer than cuniform osteotomy of neck.
Further slipping is prevented.
By these osteotomies one can correct angulation, rotation, flexion, extension Deformity of bones to restore motion for patient with stiff hip.
Deformities in septic arthritis
Malunion of I/T femurs
There are three types of corrective osteotomies
Close wedge - transverse closing wedge provide good bony apposition and is stable, however, it shortens the extremity.
Open wedge - simple and lengthens the extremity however. bony apposition is limited, union is delayed in adults and it is initially unstable.
Ball and Socket type - achieves stability without shortening the extremity; however, extensive dissection is required, and in severe biplame deformities an accurate and stable osteotomy is difficult to perform.
In Ball & socket type of osteotomy concave surface in created in the proximal fragment of convex surface at the distal fragment, at intertrochantaric level & fixed in place by plate.
In those case which present late (1-5 wks.), are difficult case to treat because
Close reduction is not possible.
Open reduction is associated AVN
In young Pt. with viable femoral head & nonunion options are-
Mcmurray & Pauwel’s ‘y’ osteotomy
Angulation Osteotomy (Schanz)
Dickson geometric osteotomy
In old Pt.-
Girdle stone osteotomy
Extends from lateral aspect of shaft at level just below the lower border of lesser trochanter and terminates medially between lesser trochanter and lower border of neck.
Shaft is displaced medially.
Mechanical Advantage :-
Line of weight bearing shifted medially.
Shearing forces at the nounion is decrease because fracture surface become more horizontal
These advantages are greater after angulation osteotomy.
The 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.Then the limb is rotated inward and outward to remove any bony spike
Fixation of osteotomy - By Compression nail plate./Castle Plate.
Instability - Degenerative changes in normal head
Shortening - AVN when neck have been fractured
Medial displacement of shaft compromise the insertion of femoral stem of total hip.
Advantage -Changes line of fracture to horizontal,callus may incarporate fracture
DICKSON HIGH GEOMETRIC OSTEOTOMY
Principle - the line of vertical force is converted to a horizontal (impacting force). In this distal fragment is abducted to 60° after making osteotomy just below the grater trochanter & fixed with plate.
High rate of union
Improves abductor strength
GIRDLE STONE OSTEOTOMY
In this head & neck of femur are excised at Inter trochanteric level to create pseudo arthrosis in order to improve stability. Angulations Osteotomy is added.
Non union #.neck femur [in elderly pt.]
AVN of femoral head.
Painless mobile hip joint.
These procedure have achieved best result for small and medium sized lesion. 1<30% femoral head involvement in young pt.
All osteotomies are designed to transfer the weight bearing forces form the necrotic area to the cartilage on the sound part of the femoral head to allow healing of necrotic area by hyper vascularisation of upper part of femur.
Femoral head is rotated anteriorly (45 0 - 90 0 ) by handling proximal pin.
OSTEOTOMY IN PERTHE'S DISEASE
Varus Derotational Osteotomy
Combined Procedure -
MRI / Arthrogram before surgery is mandatory.
Varus/derotation osteotomy of this embodies the principle of “containment” of the diseased femoral head in the treatment of Legg - Calve-Perthes disease.
Guide pin inserted compression screw is placed over guide wire.
Appropriate angled osteotomy is made.
Wedge is removed.
Make osteotomy as proximal as possible just below lag screw for -
Better correction of deformity.
Reduce the osteotomy and fixed with plate and compression screw.
SUBTROCHANTERIC DEROTATION AND VARUS OSTEOTOMY
The aim of surgery is to center the whole "plastic" epiphysis inside the joint cavity, keeping it well covered by the roof of the acetabulum and allowing the child to walk so that the redistributed intra-articular pressures will contribute the molding of a more normal joint.
A small 4-hole plate is bent to the desired angle, and a subtrochanteric osteotomy is done followed by derotation and yarns angulation of the shaft. A double hip spica is applied and the removed 2 months later. When the osteotomy site is united, the child is encouraged to walk, at first in warm water pool, then with walking aids and finally without support.
VARUS DEROTATION OSTEOTOMY
The operation is best suited for early stage of Leg-Calve-Perthes’ disease, preferably those under the age of 7 years.
Axer : Described lateral open wedge osteotomy for children < 5 years with perthes disease. Defect laterally fills rapidly in young children > 5 years of age delayed or non union may occur.
Valgus subtrochanteric osteotomy - for Hing Abduction
Shelf Augmentation – Coxa Megna.
Chilectomy - Malformed head in late III Group.
Chiar's Pelvic Osteotomy - Large Malformed Femoral Head with Subluxation laterally.
Apley's System of Orthopaedics and Fractures - Loui's Soloman 8th Edition.