Osteotomies around the hip

OSTEOTOMIES AROUND THE HIP
Dr.Bahaa Ali Kornah
Prof. Of Orthopedic
Al-Azhar University
Cairo -Egypt
bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

Dr. Bahaa Ali Kornah
Prof.. Of Orthopedic
Al-Azhar University
Cairo - Egypt
Bahaa Kornah. Al-Azhar Un. Cairo EGYPT
‫وبركاته‬ ‫هللا‬ ‫ورحمة‬ ‫عليكم‬ ‫السالم‬

• DEFINITION
– An osteotomy is a surgical operation whereby a
bone is cut to shorten, lengthen, or change its
alignment performed with or without removal of
a portion of the bone.

Osteotomies…...

OSTEOTOMIES AROUND THE HIP
femoral
pelvic

• What surgical options are available ?
1. Arthrodesis
2. Arthroplasty
3. Osteotomy

• Arthrodesis
 not commonly performed
 young patient
 active
 heavy labor
 unilateral stiff, painful hip
 normal lumbar spine, ipsilateral knee and contralateral
hip

• Partial
• Total
Arthroplasty

Osteotomies….
• Femoral valgus / varus
flexion / extension
rotational
• Pelvic reconstructive
salvage
• Combinations

• A pelvic osteotomy is a joint preservation
operation designed for realigning the
dysplastic acetabulum and providing a
biomechanically sound hip joint with
essentially normal bearing surfaces

Osteotomies….
 Reconstructive osteotomies seek to normalize joint
pressures and unit loads by normalizing the malaligned
anatomy
Their aim is to restore a normal or near normal prognosis to a
hip in which osteoarthrosis is destined to develop
 Salvage osteotomies treat established osteoarthrosis and
seek to relieve pain, improve function and preserve bone
stock
Delay the performance of a total joint arthroplasty

Indications
Reconstructive Salvage
• less than 25 yrs
• minimal but progressive
symptoms
• near normal ROM
• near normal function
• reversible anatomy
• congruent but
malaligned surfaces
• poor prognosis left
untreated
• Less than 50 yrs
• moderate to severe
symptoms
• > 60 degrees flexion
• fair to poor function
• irreversible anatomy
• incongruous and/or
joint space narrowing
• poor prognosis left
untreated

Overview of Pelvic Osteotomies

Pe

• HIP BIOMECHANIC
– Hip designed to support BW permit mobility
– Max ROM 140- Fle/Ext,75-Abd/Add
– Functional ROM 50-Fle/Ext

Hip Biomechanics
• Forces acting across a hip joint can be
measured either
– Directly with implanted strain-gauged end
prosthesis
– Mathematical model calculations – 2D static
analysis

• 2D STATIC ANALYSIS
– One legged stance 5/6 BW on femoral head
– Ratio of lever arms to BW 3:1

• BIO MECHANICS
– Forces across hip joint
BW
Ground reaction forces
Abductor muscle forces
– Improving abductor function
will decrease joint reaction forces

• HIP BIOMECHANICS
– As the ratio of length of the lever arm of body weight to
that of the abductor musculature is > 3:1,the force of
abductor muscle must approx 3 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

Biomechanics of Cane
• Cane in Contra lateral
hand decreases JRF
• Long moment arm
makes so effective
• 15% BW to cane
reduces joint contact
forces by 50%

Biomechanics
• Dynamic analysis much more complex
• Forces across hip joint combination of:
– Body weight
– Ground reaction forces
– Abductor muscle forces

Biomechanics
• Improving abductor
function will decrease
joint reactive forces

Dysplasia and Subluxation
• Dysplasia (anatomic and radiographic def’n)
– inadequate dev of acetabulum, femoral head or both
– all subluxated hips are anatomically dysplastic
• Radio logically difference between Subluxated and dysplastic
hip is disruption of Shenton’s line
– subluxation: line disrupted, head is superiorly,
superolaterally or laterally
displaced from the medial wall
– dysplasia: line is intact
• important because natural history is different

Acetabular dysplasia, the stress across the hip
joint is increased as a consequence of the
following:
A decreased acetabular weight-bearing zone
Increased joint reaction forces across the hip
joint secondary to the laterally displaced
center of rotation of the hip

Natural History
• Subluxation predictably leads to degenerative joint
disease and clinical disability
– Mean age symptom onset
36.6 in females and 54 in men
– Severe X-ray changes
46 in female and 69 in males

Hip dysplasia - what is this disease ?
Hip dysplasia results in
• Increased hip laxity leading to subluxation
(loose hips)
• Later develops arthritis

• In acetabular dysplasia
the acetabulum (socket) is too shallow or
deformed. The center-edge angle is measured
as described by Wiberg.
• femoral dysplasia are Two forms of
1. coxa vara, in which the femur head grows at
too narrow an angle to the shaft, and
2. coxa valga, in which the angle is too wide.

Crowe classification

Hip dysplasia - clinical signs
• May be radiologically abnormal but show
no clinical signs
• Gait abnormalities
• Weakness hip abd.
• Arthritis may be crippling in old age

Hip dysplasia – diagnosis
• Clinical examination
• Radiographs (x-rays)
– These have to be accurately positioned
– Anaesthesia or heavy sedation is thus required.
– Usually take extended and flexed hip views

Measurements of Dysplasia….
Perkins’ line
Hilgenreiner’s line
Acetabular index < 30 degrees
Newborn < 27.5 degrees
Shenton’s line

Centre edge angle of Wiberg
Normal > 25degrees
Acetabular index
Normal 10 +/- 2 degrees
Lateral subluxation

Wiberg angle
Sourcil

Measurements of Dysplasia
Anterior centre edge angle
measured on the false-
profile view
of Lequesne and de Seze
taken obliquely at 65
degrees
normal > 20 degrees

CT scanning becoming
increasingly useful in
the pre operative
measurement and
planning of osteotomy
cuts etc.

MRI scans are
particularly useful in
detecting labral
lesions and early
degenerative changes
such as cartilage
damage, cysts or
ganglion formation

• OSTEOTOMY AROUND HIP CLASSIFICATION
– According to Anatomic Location
• Femoral Osteotomy
– High Cervical.
– Intertrochanteric Osteotomy.
– Subtrochanteric Osteotomy.
– Greater Trochanteric.
• Pelvic Osteotomy.
– Salvage Osteotomies : e.g.. Chiari, Shelf.
– Reconstructive Osteotomies : e.g.. 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.
» 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.
» Extra capsular 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.
– Varus Osteotomy.
– Rotational Osteotomy
• In congenital dislocation.

Reconstructive
• Redirectional
• Salter
• Sutherland
• Steel
• Ganz
• Reshaping
• Pemperton
• Dega
• Lance
• Wagner
Salvage
•Shelf
•Chiari

• Reshaping ost.
change the shape
and size of the
acetabulum and
are used only
when the
triradiate
cartilage is open
• Redirectional ost.
• change the
orientation of the
acetabulum without
changing the shape
or dimensions of the
acetabulum.

Approach For Open Reduction
Smith-Peterson
• Provides exposure to
– hip joint
– ileum
• Indications
– open reduction of
congenital hip dislocations
– synovial biopsies
– intra-articular fusions
– THA
– excision of pelvis tumors
– pelvic osteotomies

Internervous plane
Superficial
Sartorius (femoral n.)
tensor fasciae latae (superior
Gluteal n.)
Deep
rectus femoris (femoral n.)
gluteus med. (superior
gluteal n.)

•
make long incision following anterior half of iliac crest to
ASIS
from ASIS curve inferiorly in the direction of the lateral
patella for 8-10 cm
Superficial dissection
identify gap between Sartorius and tensor fasciae latae
dissect through subcutaneous fat (avoid lateral femoral
cutaneous n.)
incise fascia on medial side of tensor fascia latae
detach origin of tensor fasciae latae of iliac to develop
internervous plane
ligate the ascending branch of the lateral femoral circumflex
artery (crosses gap between sartorius and tensor fascia
latae)
Incision

Incision
Deep dissection
identify plane between rectus femoris and gluteus
medius
detach rectus femoris from both its origins
retract rectus femoris and iliopsoas medially and
gluteus medius lateral to expose the hip capsule
adduct and externally rotate the hip to place the
capsule on stretch
incise capsule with a longitudinal or T-shaped capsular
incision
dislocate hip with external rotation after capsulotomy
is complete

Dangers
Lateral femoral cutaneous nerve
reaches thigh by passing approximately 10-15mm
lateral to ASIS, under inguinal ligament
injury may lead to painful neuroma or decreased
sensation on lateral aspect of thigh
Femoral nerve
should remain protected as long as you stay lateral to
sartorius muscle
Ascending branch of lateral femoral circumflex artery
be sure to ligate to prevent excessive bleeding

(A) REDIRECTIONAL (COMPLETE) OSTEOTOMIES
• These procedures rotate ! hyaline cartilage of ! acetabulum into a more
desirable position over the head.
• Redirectional osteotomies are the most useful of the acetabular
procedures.
• They have application over a wide range of ages.
• Do not alter the shape of the acetabulum.
• PREREQUISITS: They require spherical congruence head.
• TYPES:
• 1- Single innominate osteotomy (Salter, Hall,& Kalamchi procedures).
• 2- Double innominate osteotomy (Sutherland procedure).
• 3- Triple innominate osteotomies (Steel procedure and Tonnis procedure).
• 4- Ganz quadrible osteotomy.

Redirectional Osteotomy

Salter Osteotomy
• Single Innominate osteotomy
• Acetabulum together with ilium and pubis
rotated
• Held by wedge of bone
• Iliopsoas & adductor tenotomies common
• 18 mon to 6 years

Salter osteotomy for congenital dislocation of hip

• Idea:
• The osteotomy is performed by a transverse linear cut
above the acetabulum at the level of AIIS. The entire
acetabulum together with the pubis and ischium is rotated
as a unit (anteriorly and laterally), the symphysis pubis
acting as a hinge. The osteotomy is held open anterolateral
by a wedge of bone, and thus the roof of the acetabulum is
shifted more anteriorly and laterally.
• Indications:
• 1]. Mild to moderate DDH éout significant incongruity
• 2]. DDH of 6-8 y old
• 3]. residual subluxation In adult é reasonable mobile and congruous hip
(up to fifth decade)

• Contraindication:
• 1]. Non concentric hip.
• 2]. Non congruent
• 3]. Severe dysplasia
• 4]. Stiff hip
• 5]. OLD cases (relative as there is no upper limit for
Salter especially the residual deformity)

• PREREQUISITES
• 1]. CONCENTRICALLY reduced
• 2]. CONGRUENT
• 3]. MOBILE
• 4]. MILDLY dysplastic (Salter can not chang the depth)
• 5]. Head must be at ! level of acetabulum >>> traction/femoral
shortening/contracture release
• Advantages
• 1]. PHYSIOLOGIC head coverage é the hyaline acetabular roof (best for
remodelling & WB)
• 2]. It does not change the ACETABULAR CAPACITY
• 3]. It doesn't ’t disturbed ACETETABULAR GROWTH
• 4]. SIMPLE single osteotomy
• 5]. RAPID CONSOLIDATION early mobilization & loading.

• Disadvantages
• 1]. Inherently unstable, so IF by pin is needed é the hazards for other
operation
• 2]. Does not increase the Acetabular depth
• 3]. It is not suitable for cases é postero-superior uncoverage (e.g. CP
uncoverage)
• Complications
• 1]. Transitory STIFFNESS: ð joint penetration by a K-wire ...... ...................... 11.6%.
• 2]. SEPTIC problems ................................................................. .. 9.4%.
• 3]. RESUBLUXATION or redislocation .......................... 4.4%.
• 4]. AVN ............................................................................. ..... 3.3%.
• 5]. osteotomy Medial DISPLACEMENT (ð poor fixation or osteotomy opening ....... 3.3%
• 6]. PREMATURE CLOSURE of triradiate cart: ð extensive inner periosteal exposure
• 7]. GREENSTICK FRACTURES around ! knee > delay WB ........................................ 3.3%

1. DOUBLE INNOMINATE OSTEOTOMY
(Sutherland procedure).
• Idea:
• It’s simply a SALTER
OSTEOTOMY + PUBIC
OSTEOTOMY medial to the
obturator foramen, in the
interval between the
symphysis pubis and pubic
tubercle. So, a 3rd osteotomy
through the ischial ramus
becomes unnecessary.

• 1. DOUBLE INNOMINATE OSTEOTOMY
• (Sutherland procedure).
• Advantages:
• 1] it has no advantage over triple
• osteotomy as regard the degree of acetabular rotation. But, it needs simpler
preparation, & operation can be performed through 2 simple incisions.
• 2]. The procedure is indicated in pts. > 6y. It can be performed in adolescents &
adults.
• hip must be reducible e’out advanced deg . change particularly at ! acetabulum .
• Disadvantages
• 1]. The fixation is uncomfortably >> close to vital components of !
urogenital system
• 2]. The axis of rotation of the inferior fragment (near the symphysis>>>>>
prominence of the ramus at the site of the osteotomy.
• 3]. The versatility of correction of the acetabular defect (when abnormal
direction or abnormal configuration ) is < that e’ a Pem berto n ’s
osteotomy o r trip le osteotom y.

• Complications
• 1]. Inward rotation of the acetabular fragment and non-
union at the site of innominate osteotomy due to unsecured
pin fixation of the graft.
• 2]. Extraperitoneal tear of the bladder.
• 3]. Temporary scrotal or labial swelling in all patients.
• 4]. Narrowing of the bi-ischial diameter of the pelvic, due to
the planned medial displacement of the acetabular
fragment.

Steel Triple Innominate
Osteotomy
• Indication : DDH in
older child
• Need good ROM
• Secure with bone
graft & AO screw
fixation

TRIPLE PELVIC OSTEOTOMY
Steele’s procedure, which combines a standard Salter
innominate osteotomy with a high ischial osteotomy and a
pubic osteotomy close to the acetabulum.

Triple Innominate Osteotomy

Steel Osteotomy
• Contraindications
– Limited ROM
– Incongrous reduction
– Significant joint space narrowing /
degenerative arthritis
• Two incision approach

A, Osteotomies to be performed in iliac wing and superior and inferior pubic rami.
Note wedge of bone to be taken as graft from superior most portion of ilium
B, Lateral view showing graft in place and fixation with two KW

Steel triple innominate osteotomy
and 1 y follow up

• TRIPLE INNOMINATE OSTEOTOMY
• (Steel procedure and Tonnis procedure)
• Idea:
• In the triple innominate osteotomy (Steel), the ischium, the superior pubic
ramus, and the ilium superior to the acetabulum are all divided, and the
acetabulum is repositioned and stabilized by a bone graft and metal pins .
• Indication:
• 1]. Skeletally MATURE (poor remodelling of the acetabulum)
• 2]. SEVERE dysplasia
• 3]. RESIDUAL SUBLUXATION

• Advantages:
• 1]. PHYSIOLOGIC Reduction (Hyaline Acetabulum)
• 2]. LARGE CORRECTION
• 3]. NO DISTORTION Of The Acetabulum
• 4]. LESS AVN
• 5]. Allows Some MEDIALIZATION Of The
Acetabulum
• 6]. NO AGE LIMIT (done after closure of the
triradiate cartilage)

• Prerequisites
• 1]. CONCENTRIC reduction
• 2]. CONGRUENT
• 3]. MOBILE é range of abduction (éout it is not possible at operation to
rotate the acetabulum)
• 4]. Avoid advanced OA (MODERATE OA is accepted)
• Complications
• 1]. NON UNION of one of the osteotomies (if excessive
acetabular rotation)
• 2]. INADEQUATE COVER of the femoral head
• 3]. FAULTY PIN PLACEMENT loss of reduction.

Periacetabular Osteotomy
• Devised by Ganz
• Introduced in 1988 by Ganz !
periacetabular osteotomy allows
extensive acetabular reorientation,
including med. & lat. displacement.
• Indication - DDH in adolescents &
adults
• Achieves correction of containment
& congruency

Periacetabular Osteotomy -
• Advantages
• Single incision
• Permits extensive reorientation
• Preserves blood supply
• Posterior column remains intact – true pelvis unchanged
>>>>immediate postoperative mobilization of the patient is
possible
• Pelvic diameter is maintained, allowing normal child delivery
in female patients and affording access for the arthrotomy at
the same time
• Preferred reconstructive osteotomy for acetabular dysplasia

• 5. PERIACETABULAR (GANZ) OSTEOTOMY:
• Idea:
• Osteotomies are performed in pubis, ilium, and ischium.
• A vertical post.-column osteotomy connects ! post. extremes of iliac &
ischial osteotomies 1 cm ant. to ! sciatic notch (the posterior column is
split vertically).

PERIACETABULAR (GANZ)
OSTEOTOMY

• Advantages:
• 1]. Very STABLE as no complete cut is made into the sciatic notch.
• 2]. NO CAST is required & Immediate crutch weight bearing
• 3]. NO AVN (Preservation of the blood supply to the acetabular
fragment)
• 4]. SINGLE APPROACH.
• 5]. PRESERVATION OF THE SHAPE of the pelvis normal vaginal delivery.
• Disadvantage.
• 1]. DIFFICULT to learn.
• 2]. HETEROTROPIC bone formation
• 3]. DVT
• 4]. Pubic NONUNION.

Reshaped

Pemberton Osteotomy
• Pericapsular osteotomy for residual dysplasia
• Hinges through the triradiate cartilage – must
be open!!
• Changes the volume & orientation of
acetabulum
• Although good results
• Recommend 6 to 8 years

• PEMBERTON OSTEOTOMY
– 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

• PEMBERTON OSTEOTOMY
– DISADV-
– Technically more difficult .
– Alters the configuration and capacity of
acetabulum and produce joint incongruity that
requires remodelling
– AGE- 18months- 10 yr
– AFTERCARE- spica cast for 8 to 12 weeks

Pemberton Osteotomy

• 3. COMBINATION PELVIC
OSTEOTOMY (PEMBERSAL)
• Idea
• It is a combination of Pemberton & Salter
osteotomies.
• The Pemberton osteotomy is carried through
• ! triradiate cart. deep into the body of the ischium.
• When the osteotomy is opened, a green-stick
fracture forms through the rest of the ischial body.
The distal pelvic fragment rotates about an axis
through the symphysis & the ischial green-stick
fracture. Also, the acetabular roof is rotated
downward & laterally, wrapping around head, hinging
through ! triradiate cart.

• Advantages:
• 1]. Large correction
• 2]. Less acetabular distortion than Pemberton ’s osteotomy.
• 3]. Internal fixation is not required
• 4]. It combines the advantages of the Pemberton and Salter
pelvic osteotomies
• Indication:
• 1]. Persistent dysplasia
• 2]. Severe dysplasia
• 3]. Failure of coverage after successful OR or CR
• 4]. Excellent procedure for older children é less acetabular
remodelling

• Technique of Pembersal combination
osteotomy:
• 1]. An anterior iliofemoral approach exposes the ilium subperiosteally.
• 2]. The osteotomy is begun as for the Pemberton ’s procedure,
approximately 10 mm above
• AIIS. It parallels ! acetabular dome & extends downward toward !
ischium. In contrast to the Pemberton’s osteotomy, the osteotomy
continues through ! ilio ischial limb of ! Y cartilag e,deep into ! body of !
ischium.
• 3]. Opening the osteotomy creates a green-stick fracture through ischeal
body.
• 4]. Hinging occurs through ! ischium & triradiate cartilage acetabulum
is reoriented as in the Salter’s & d eep en ed as in the Pemberton
procedure.

• (B) Reshaping (Periarticular) Osteotomies
• In periarticular osteotomies the osteotomy parallels the joint surface
and allows repositioning, and sometimes reshaping of the acetabulum.
• 1. LANCE PROCEDURE
• (Marginal periarticular osteotomy)
• It has been described as a lip osteotomy that extends a variable
distance from ! Acetabular margin over ! sup. dome of ! socket. It !
retention capability of the acetabulum.
• 2. DEGA OSTEOTOMY:
• The Dega osteotomy is an acetabuloplasty that also changes acetabular
configuration and shape.
• It increase posterolateral coverage by means of an osteotomy of ! iliac
lat. cortex only, hinging through the open Y cartilage.
• The 1ry indication for this osteotomy is the presence of a capacious
acetabulum with POSTEROLAT.DEFICIENCY, as is often found in CHILDREN
WITH CP. Some authors also use it for persistent acetabular dysplasia in
DDH.

Dega osteotomy
- incomplete transiliac osteotomy which
penetrates the anterior and middle portions
of the inner cortex of the ilium, leaving an
intact posterior hinge (intact posteromedial
iliac cortex and sciatic notch);

Salvage procedures

Chiari Osteotomy

Chiari Osteotomy
• Devised by Chiari 1950’s
• Salvage procedure
• Relief of pain in incongrous hip
• Increases coverage by medializing hip centre
• Fibrocartilage transformation of superior
capsule

• PALLIATIVE OPERATION
– Reserve for cases is which reduction is not
possible by either open or closed reduction as in
old unreduced congenital dislocation.
– Designed to improve :
• Stability.
• Decrease lordosis.
• Control pain arising from lower back/hip.

B. CHIARI OSTEOTOMY
• Idea:
• Innominate osteotomy with medial
displacement of the acetabulum, to create a
lateral extension for the acetabulum so the
head would be beneath a surface of bone
and capsule

• Indications
• 1]. SEVERE and Residual DDH
• 2]. INCONGRUENT DDH
• 3]. DDH with OA
• 4]. DEFICIENT acetabulum that can not be corrected by redirectional
osteotomies
• 5]. DEFORMED HEAD
• 6]. PARALYTIC dislocations
• 7]. PERTHE'S Coxa magna
• 8]. Contraindication for any reconstructive osteotomy
• Contraindications:An absence of any of the indication
• 1]. No Incongruence
• 2]. No (Or Severe) OA
• 3]. Markedly ROM (at least 90 degrees of flexion)
• 4]. Upward Subluxated Hip (difficult to perform)
• 5]. Broken Shenton (>1.5mm)

• Advantages
• 1]. Postpones the need for THR &improved roof cover for THR
• 2]. The SHELF IS A VASCULARIZED iliac bone, not prone to absorption
• 3]. STABLE
• 4]. NO UPPER AGE LIMIT for this procedure఑
• Disadvantages
• 1]. Superior joint capsule is replaced é FIBROCARTILAGE
• 2]. OBLIQUITY of the true acetabulum.
• 3]. PELVIC DIAMETER may affect childbirth
• 4]. Slight SHORTENING of the limb.

• Complication of Chiari osteotomy:
• 1]. Sciatic palsy: ð angulation at the osteotomy level & sciatic notch.
• 2]. Too low osteotomy insufficient space for capsule to develop a
cartilage
• 3]. GREENSTICK FRACTURE of the ilium.
• 4]. INADEQUATE DISPLACEMENT: or ( abduction or less correction)
• 5]. CHONDROLYSIS: 3mo after surgery, pain, and ROM
• 6]. DAMAGE OF THE CAPSULE ROM

• CHIARI OSTEOTOMY
• 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.

Pelvic Osteotomies….

A. SHELF PROCEDURE (Staheli)
• Idea:
• Moving an anterolateral bony shelf at or near the outer edge of the
acetabulum to construct a bony buttress,
• acetabular volume, and prevent head migration.
• No alteration of the shape of the acetabulum.
• The fibrocapsule change to fibrocartilage.
• Walker technique of Slotted acetabular
augmentation (Modified Staheli)
• Elevate the entire iliac crest/hip-abductor mechanism as a single unit
• A slot is fashioned over the acetabular margin with a high-speed burr
• Bone graft will be placed in the slot prepared
• No hip spica and early motion is an advantage of Walker protocol

Femoral osteotomy
shape
• valgus / varus
• flexion / extension
• Rotational
• Combined

Femoral osteotomy
site
•Femoral Osteotomy
–High Cervical.
–Intertrochanteric Osteotomy.
–Subtrochanteric Osteotomy.
–Greater Trochanteric.

Osteotomy: Historical Review
• Medial Displacement Osteotomy
Mc Murray
Lorenz

Angulation's Osteotomy
• Pauwels
• Bombelli
• Muller

Pauwels
• Promoted the use of angulation
osteotomy with I.F.

Pauwels
• His initial interest was:
Salvage of non-union of femoral neck by
valgus osteotomy

OSTEOTOMY

PAUWELS Y SHAPED
osteotomy

Coxa Vara

Bombelli
• Modified
• many of Pauwels concept, he
became one of the world’s
leading osteotomy surgeons
today

Muller
• Pre-operative planning
• AO instruments and implants

Preoperative Planning
Angle of Correction
Ununited Fracture neck:
Pauwels concept
Malunited Fracture:
Tracing & paper cut out

• The plan should
contain also all
the steps
necessary for the
procedure

• post.op.bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

• One month post.op.bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

• 4 months p.op.bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

Varus osteotomy increases weight bearing area of femoral
headwhile relaxing all three important muscle groups around
hip jointbahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

Three types of wedges cut for varus osteotomy. A, Original technique of Pauwels with
proxima osteotomy made transversely at distal end of greater trochanter. This type of
osteotomy makes it more difficult to correct rotation and to use right-angled blade plate. B,
Original Müller technique of excision of wide wedge based medially with distal osteotomy cut
transversely across shaft at just above level of lesser trochanter. C, Later technique of Müller using
small half wedge cut medially and transposed laterally.

VARUS OSTEOTOMIES

valgus intertrochanteric osteotomy

valgus intertrochanteric osteotomy
(VITO)

types for fixation
• angled blade plates (ABPs),
• the dynamic hip screw (DHS),
and
• the dynamic condylar screw
(DCS).

Sarmiento Technique

Dimon and Hughston :
Describe technique of Trochanteric osteotomy with
valgus nailing and medial displacement to improve
stabity there techniques are occasionally useful in some
extremely comminuted fractures.
Recent studies have indicated that anatomical reduction
geater sheaing by
displacement osteotomy.

DIMON AND HUGHSTON METHOD OF
INTERTROCHANTERIC OSTEOTOMY

Is a disorder in which there is a displacement of the capital
femoral epiphysis form the metaphysis through the physeal
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-
Varus
Hyper extension
Moderate Severe external rotation

The osteotomy to correct these
deformities work at two sites.
Through the femoral neck
(closing wedge osteotomy)
Through the trochanteric

McMURRAY

MC-MURRAY OSTEOTOMY

Corrective osteotomy
•Brackett ball and socket
•Osteotomy
Whitman closing wedge
Osteotomy
Gant-opening wedge
Osteotomy

-

VARUS DEROTATION OSTEOTOMY

Bahaa Ali Kornah
bkornah@gmail.com
‫د‬/‫قرنة‬ ‫بهاء‬bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

Osteotomies around the hip

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