Osteotomies around hip

1. Department of Orthopaedics
Siddhartha Medical College,Vijayawada
OSTEOTOMIES AROUND THE HIP
Dr.T.Anil kumar
Final year postgraduate

2. • Surgical corrective procedure used to
- obtain a correct biomechanical alignment
of the extremity
- achieve equivocal load transmission
• + / - removal of a portion of bone.

3. Objectives
• Improve coverage of head
• Containment of head
• Moves normal articular cartilage into weight
bearing zone
• Improves motion
• Relieves pain
• To correct leg length inequality by shortening
/ lengthening

4. The Neck of Femur
• Angulated in relation to the shaft in 2 planes :
sagittal & coronal
• Neck Shaft angle
– 140 deg at birth
– 120-135 deg in adult
• Ante version
– Anteverted 40 deg at birth
– 12-15 deg in adults

5. Acetabular Direction
• long axis of acetabulum
points
– forwards : 15-200
ante version
– 450 inferior inclination ante version

6. Biomechanics
• Forces acting across
hip joint
 Body weight
 Abductor muscles
force
 Joint reaction force

7. defined as force generated within a joint in response to forces
acting on the joint
in the hip, it is the result of the need to balance the moment
arms of the body weight and abductor tension
maintains a level pelvis
Joint reaction force
-2W during SLR
- 3W in single leg stance
-5W in walking
-10W while running
Joint reaction force

10. Biomechanics in neck deformities :
Coxa valga
• Increased neck shaft angle
• GT is at lower level
• Shortened abductor lever arm
• Body wt arm remains same
• Increased joint forces in hip during one leg
stance
• Less muscle force required to keep pelvis
horizontal

11. Coxa valga
Resultant force R is
more than a normal hip

12. Coxa Vara
• Decreased neck shaft angle
• GT is higher than normal
• Increased abductor lever arm
• Abductor muscle length is shortened
• Decreased joint forces across the hip
during one leg stance
• Higher muscle force is required to keep
pelvis horizontal

13. Coxa Vara
Resultant force R is less than
a normal hip

14. Radiographic parameters used
Centre Edge Angle Acetabular Index
• formed b/w Hilgenreiner line
and a line drawn along the
acetabular surface
• Newborns : 27.5°
6 months age : 23.5°
2yrs age : 20°
• Maximum upper limit : 30°
• Formed b/w Perkin line & a
line that connects lateral
acetabular margin to the centre
of the femoral head
• Measures the position of hip
• 6-13 yrs : >19 °
>14 yrs : >25°
• Angle increases with age

15. CE ANGLE of WILBERG ACETABULAR INDEX

16. FALSE PROFILE VIEW
• patient standing 65 degrees
oblique to the x-ray beam with
the foot parallel to the
cassette.
• center–edge angle is
constructed from the
intersection of a vertical line (V
) through the center of the
femoral head (C ) with a line
(A) from the anterior edge of
the sourcil to the center of the
femoral head.

17. Osteotomies around the hip are classified as
Proximal Femoral Osteotomies
According to Anatomical location
1. High cervical
2. Intertrochanteric
3. Subtrochanteric
4. Greater Trochanteric
Based on displacement of distal
fragment
• Torsional/derotation
• Trans positional
• Angulation
– adductional/varus
– abductional/valgus
– flexion/ extension osteotomies
Pelvic osteotomies
1.Redirectional :
Single Innominate – Salter
Double Innominate – Sutherland
Triple Innominate - Steel, Tonnis
Periacetabular Osteotomies Ganz(Bernese)
Sherical acetabular osteotomies – Ninomiya
-
Dial,Wagner
2.Volume reducing : Pemberton,Dega, San
Diego
3.Greater Load bearing surface :
Shelf operation ( STAHELI)
Chiari Osteotomy

18. • Based on Indications
– To obtain pain relief
• Osteoarthritis.
– Pauwels varus osteotomy.
– Pauwels valgus osteotomy.
– McMurrays osteotomy
– In proximal femur fractures
• 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

19. UNREDUCED CDH
- Lorenz bifurcation osteotomy
- Schanz low sub trochanteric osteotomy.
- Pemberten acetabuloplasty.
- Salter Osteotomy
CONGENITAL COXA-VARA
- Pauwel’s Y osteotomy
-ValgusIntertrochanteric osteotomy – Borden,Wagner
LEG-CALVE PERTHE’S DISEASE
- Varus de-rotation osteotomy
- Salter osteotomy
- Shelf
- Chiari osteotomy.

21. . AVN
- Sugioka – Trans trochanteric osteotomy
- Varus de-rotation osteotomy
- Pauwels Y osteotomy
SLIPPED CAPITAL FEMORAL EPIPHYSIS.
• A) Closing wedge osteotomy of neck:
a. The technique of Fish
b. Technique of Dunn just distal to slip
c. Base of neck technique by Kramer et al d.
d. Technique of Abraham et al
• B) Compensatory osteotomies:
a. Ball and socket osteotomy
b. Biplanar IT osteotomy (Southwick)
OSTEOTOMIES IN PARALYTIC DISORDER OF HIP
– Varus osteotomy
– Rotation osteotomy
– Extension osteotomy.

22. Pelvic Osteotomies – SALTER INNOMINATE
• the entire acetabulum together with pubis and ischium is rotated as
a unit
INDICATIONS: <10–15° of correction of acetabular index is needed
• CDH in children from 18 months to 6 years of age
• Congenital subluxation upto early adult life.
• LCPD – onset of disease after 6 yrs age
- moderate – Severely affected head
- loss of containment
PREREQUISITIES:
-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.
-ROM of hip must be good

23. Osteotomy made
from AIIS to
Greater Sciatic
notch notch

24. Graft is taken
from iliac crest
and trained to the
shape of a wedge
The distal segment
is shifted forward,
downward and
outward

25. Place the graft into open
segment anteriorly

26. Secure it by passing K-
wires from proximal
fragment through graft
into distal fragment
taking care not to enter
acetabulum

27. Advantages: No effect on acetabular capacity
Technically less demanding
Disadvantages: Relatively unstable
Needs internal fixation – k wires
Needs second surgery for pin removal
Complications :
• Neurovascular damage – Sciatic nerve,
- lateral femoral cutaneous nerve
- nutrient vessels to tensor fascia lata
• Joint penetration of k-wires

28. Kalamchi modification of Salter Osteotomy
• Displacing the distal
fragment into the
posterior notch in the
proximal fragment
• To avoid increased
pressure on the femoral
head

29. SUTHERLAND Double Innominate Osteototmy
• Indication: age 8 – 15 yrs, DDH
• following Salter osteotomy,
- 2nd osteotomy – Pubic osteotomy
- medial to obturator foramen in the
interval b/w symphysis pubis and
pubic tubercle
- wedge of bone 7- 13mm in diameter just lateral to
symphysis parallel to it
• Displace the acetabular fragment distally and anteriorly

30. Advantages:
• Addition of pubic
osteotomy increased the
amount of acetabular
rotation & coverage of
femoral head
• Femoral head could be
shifted medially ,
reducing the length of
femoral lever arm

32. Triple Innominate Osteotomy - STEEL
• INDICATIONS- Adolescents
& skeletally mature adults with
residual dysplasia &
subluxation in whom
remodelling of acetabulum is
no longer anticipated
• PROCEDURE-The ischium,
the sup pubic ramus and ilium
superior to the acetabulum is
repositioned and stabilized by
bone graft

33. 1.Osteotomy made from AIIS
to Greater Sciatic notch
1.Osteotomy
made from AIIS to
Greater Sciatic
notch

34. 2.Superior pubic ramus is
divided posteromedially
15° from perpendicular.

35. .
3. Ischial ramus is divided
posterolaterally at 45° from
perpendicular

36. • ADVANTAGE S –
• Better coverage of femoral head by articular cartilage
• Better hip joint stability,
• no need of spica cast.
• 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.

38. TONNIS TRIPLE INNOMINATE OSTEOTOMY
• Long ischial cut connects obturator foramen with the sciatic notch so
that the cut finishes proximal to the sacrospinous lig., preventing it
tethering from the acetabular fragment durnig correction
• Long cut provides good contact after displacement to prevent
pseudoarthrosis
• The iliac cut is slightly curved and the pubic is cut as in Steel
procedure
• Fixation is with screws and attaching a cerclage wire from a screw in
the pubis to a pin in the ilium.

40. Periacetabular Osteotomy – GANZ (BERNESE)
• Triplaner osteotomy 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

41. • First cut – Ischial cut , made down to the ischium, at the infracotyloid
groove , begins distal to acetabulum ,directed posteriorly aiming at the
ischial spine and ends at the posterior aspect of acetabulum
• Second cut - Superior ramus cut
- begins just medial to the iliopectineal eminence
• Third cut - made just inferior to the anterior superior iliac spine
- cut ends just lateral to the pelvic brim at the apex
between the third and fourth cuts, midway between the posterior
aspect of the posterior column and the posterior wall of the
acetabulum
• Fourth cut - travels down the posterior column to meet the first cut

43. GANZ / BERNESE OSTEOTOMY …

44. – 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.

45. • Disadavntages :
- learning curve is long and steep
- serious complications
• Complications :
- Displacement of fragments
- Delayed , nonunion of pubic and ischial osteotomies
- Loss of fixation
- Damage to lateral femoral cutaneous nerve( 50% pts
)
- Femoral nerve palsy,
- Ectopic bone formation

46. Spherical Acetabular osteotomies
• Allows rotational repositioning of acetabulum through a wide range
• Stable – no disruption of pelvic ring
• Medialisation of acetabulum is difficult if not impossible
• Anterior rotation of acetabulum – loss of flexion common
• Pain relief ,improvement in acetabular coverage in majority cases
• Ex: 1.Ninomiya spherical osteotomy
2.Wagner spherical osteotomy
3.Eppright – DIAL osteotomy

47. NINOMIYA SPHERICAL OSTEOTOMY

48. VOLUME REDUCING PELVIC OSTEOTOMIES
• These osteotomies correct the acetabulum while hinging
on portions of the symphysis pubis and the triradiate
cartilage
• Because of this second point of hinging, these
osteotomies have the potential to not only reorient the
acetabulum but also to reshape it
• They differ in the extent of the bone cut on the inner and
outer tables of the acetabulum, the extent of the
remaining hinge

49. • Pemberton cuts both the inner and the outer tables of the ilium,
and hinges on the ischial limb of the triradiate cartilage
• Pembersal extends past the ischial limb of the triradiate cartilage,
freeing the acetabulum to rotate more.
• San Diego osteotomy preserves the entire medial cortex and
cuts through the cortical bone of the sciatic notch in an attempt to
produce equal anterior and posterior coverage
• Dega osteotomy preserves the inner table of the pelvis posterior
to the iliopectineal line. It also preserves the entire cortex of the
sciatic notch.

51. PEMBERTON OSTEOTOMY
• INDICATION:
- In dysplastic hips between the age of 18 months and 6 yrs,
- >10-15 degrees correction of acetabular index required.
- Small femoral head ,large acetabulum
• PROCEDURE- pericapsular osteotomy of the ilium
• 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

54. • 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.

55. DEGA OSTEOTOMY
Age : 2 – 12 yrs
• - lower age limit for the osteotomy is primarily determined by bone
quality,which must be strong enough (on the younger end) to
support the hinge process ,yet
• not too stiff (on the older end) to hinge plastically.
• For the bone to be adequately plastic, the triradiate cartilage should
ideally be open.
Contraindications :
• acetabulum that is too small to adequately contain the femoral
head, even after reorientation

56. • Osteotomy starts above the acetabulum and proceeds
into the triradiate cartilage behind and beneath the
acetabulum
• placement of the wedges determines the area of
acetabular coverage that is improved
• Wedges placed posteriorly – posterior acetabular
coverage is augmented
• wedges are placed anteriorly and superiorly, coverage is
improved anterolaterally
• acetabular volume may be decreased by the
displacement of the osteotomy.

58. DEGA OSTEOTOMY

59. CHIARI OSTEOTOMY
• Greater load bearing osteotomy
Indications:
• Unique - only pelvic osteotomy that is indicated primarily when the
hip is incongruous and when femoral head coverage cannot be
achieved by other methods of reconstruction
• recommended when the femoral head is irregular or cannot be
centered in the acetabulum by abduction and internal rotation of the
hip
• Can also be performed in the presence of severe instability
• prevention or treatment of pain, rather than primary improvement in
hip function, is the principal objective of this procedure

60. • oblique osteotomy in a proximal and medial direction,
beginning at the lateral margin of the dysplastic
acetabulum, at an angle of 10°
• optimal location to begin the osteotomy is within 1 cm or
less of the capsular insertion on the lateral margin of the
dysplastic acetabulum.
• osteotomy that is too distal may enter the joint or place
increased pressure on the femoral head when the hip is
displaced medially.
• osteotomy that is too proximal may fail to provide
adequate load bearing for the femoral head

61. TECHNIQUE :
• 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
10° superiorly towards inner
table.

62. • 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.

63. Disadvantages
• insertions of the hip abductor
muscles are displaced
medially and proximally as the
hip is displaced along the
slope of the osteotomy
• reduce the strength of the hip
abductor muscles and
decrease their mechanical
advantage

64. Technical considerations
• Risk of Posterior displacement of the distal osteotomy fragment
• Greater risk when the osteotomy is more horizontal
• osteotomy that is curved from anterior to posterior will help resist
posterior displacement of the acetabulum
• A dome-shaped osteotomy also provides more anterior and
posterior support to the hip capsule and femoral head
• recommended that 80% of the femoral head should be covered
following displacement

66. SHELF PROCEDURES - STAHELI
• Primary indication : hip dysplasia with aspherical hip congruity
not amenable to redirectional osteotomies.
• Secondary indication : anterolateral acetabular extension in
dysplastic hips in which femoral head coverage cannot be achieved
by the more commonly performed pelvic osteotomies
• Patients aged 8 years or older with Legg-Calvé-Perthes disease,
who typically present with coxa magna and early lateralization of the
femoral head.

67. • objective is to create a
shelf, the size of which is
decided by measuring the
“width of augmentation
(WA)” using the CE angle
of Wilberg.
• Graft length(gl)= wa + slot
depth
• Achieving a center-edge
angle of 35 degrees is
optimal

69. • Shelf is constructed over the femoral head, particularly anteriorly
and laterally
• created by using local shavings of iliac bone along with a large
segment of bone from the iliac wing
• A concave slab of bone is fixed over the femoral head and
placed over the hip capsule and beneath the reflected head of
the rectus femoris
• A buttress of cancellous bone is then constructed between this
slab and the pelvis, over the acetabulum
• As the shelf matures, the contour will remodel from the pressure
of the femoral head, and the bone of the shelf will hypertroph

70. Overview of Pelvic Osteotomies

71. PROXIMAL FEMORAL OSTEOTOMIES
Based on the displacement of distal fragment
1.TRANSPOSITIONAL OSTEOTOMY:
Longitudinal axis of distal fragment
remains parallel to the longitudinal
terminal axis of proximal fragment.
Used in : Fracture neck of femur,
OA.
Eg: McMurray osteotomy,
Pauwel’s osteotomy

72. 2.ANGULATION OSTEOTOMY :
Longitudinal axis of distal fragment
forms an angle with that of proximal
fragment .
- Sagittal plane : Extension osteotomy for FFD
-Coronal plane : varus osteotomy
valgus osteotomy

73. Based on INDICATION – Osteoarthritis of hip
• AIM OF OSTEOTOMY :
1. RELIEF OF PAIN: Mechanical : reducing the ratio
between abductor and body weight lever arm,
relaxing capsule.
Haemodynamic: Also by decreasing
the intra osseous pressure.
2. CORRECTION OF DEFORMITY: flexion, adduction,
external rotation.
3. REVERSAL OF DEGENERATIVE PROCESS: helped
by increase in joint space.

74. • Osteotomies in Osteoarthritis of hip :
–Pauwels varus osteotomy.
–Pauwels valgus osteotomy.
–McMurrays osteotomy

75. McMurray’s Displacement Osteotomy
INDICATIONS:
1. Nonunion of femoral neck
2. Advanced osteoarthritis .
PREOPERATIVE PLANNING :
Determination of the size of the bone wedge to be
removed, the position of the seating chisel which will
determine the size and angle of the blade plate to be
used.
AIM :
– Line of weight bearing is shifted medially
– Shearing force at the nonunion is decreased, because the
fracture surface has become more horizontal

76. • Oblique osteotomy made in the shaft of the femur -
• Its lower border on the outer margin being slightly below
the level of lesser trochanter
• Terminates on the inner side b/w lesser trochanter and
neck
• Shaft of femur is displaced inwards by abduction of the
limb & digital pressure on the upper and outer aspect of
lower fragment – complete inward displacement

78. Postoperative care
• Mobilize the patient as soon as symptoms
permit.
• Maintain touch-down weight bearing until union
occurs.
• Active and assisted range of motion exercises
for the hip and knee.
• Once union occurs, unrestricted rehabilitation is
possible.

79. Pauwels Varus Osteotomy
AIM :
• 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° .

83. CONTRAINDICATIONS:
– Fixed external rotation of > 25°
– Flexion of 70° or less.
DISADVANTAGES:
• Shortens the limb to some degrees.
• Creates a trendelenberg gait.
• Increases the prominence of greater trochanter.
• Overloading of the medial compartment of knee.

85. PAUWELS VALGUS OSTEOTOMY
AIM:
• To 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.

86. • After insertion of guide wire & chisel 2cm proximal to
osteotomy site similar to explained before :-

87. Osteotomies in Nonunion neck of femur
DICKSON HIGH GEOMETRIC OSTEOTOMY
• Principle - the line of vertical SHEAR 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
• Lengthens limb
• Improves abductor strength

89. SCHANZ ANGULATION OSTEOTOMY
AIM :
To turn the shaft from the
adducted to abducted
position, so that the
shearing stress of weight
bearing and muscle
retraction becomes an
impaction force.
INDICATIONS:
• Nonunion fracture neck of
femur
• Congenital dislocation of
hip

90. • The femur is cut transversely at ischial tuberosity level
& the proximal fragment is adducted until it rests
against the side wall of the pelvis.
• This lengthens the distance of the gluteus medius and
provides a fulcrum so that adequate leverage of the
muscle is obtained.
• A plate is prepared and angulated sufficiently
• At operation, the bone is sectioned and the plate is
attached to proximal fragment.
• Then, the distal fragment is abducted, extended and
approximated to the distal half of the plate, which is
then attached.

92. Lorenz bifurcation osteotomy
92
– Described for congenital dislocation of hip
– In this,upper end of the distal 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

94. OSTEOTOMY FOR COXA VARA
• The normal femoral neck shaft angle in infant is 1200 to
1400, Reduction to a more acute angle constitute a
coxa vara deformity.
• Goals of treatment :
– 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 - epiphyseal angle of more than 60° .

95. • Surgeries performed are
1. Valgus Subtrochanteric Osteotomy or abduction osteotomy-
with Internal Fixation. – Borden ,Wagner
• 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.
Contd.

97. OSTEOTOMIES FOR CONGENITAL COXA VARA
PAUWEL’S “ Y “ OSTEOTOMY
• Objective :
- To place the capital femoral physis perpendicular to the
resultant compresive force
- To decrease the bending stress in the femoral neck

100. Osteotomies in AVN – Femoral head
SUGIOKA TRANSTROCHANTERIC
OSTEOTOMY
• Aim : To move the involved necrotic anteosuperior
segment of the femoral head from the principal weight
bearing area
- Transtrochanteric rotational osteotomy
- Best results for
1. small / medium sized lesions ( <30% femoral head
involvement ) in young adults
2. Idiopathic / posttraumatic osteonecrosis ( compared to
alcohol, steroid induced AVN )

101. TECHNIQUE :
• Through lateral
approach expose the
capsule, osteotomize
the greater
trochanter.
• Reflect it proximally
• Incise the joint capsule circumferentially.
• Carefully protect the posterior branch of medial
circumflex femoral artery at inferior edge of Quadratus
femoris.
along with the attached tendon of Gluteus medius,
minimus and Piriformis.

102. • Place two pins in greater
trochanter from lateral to
medial in a plane
perpendicular to femoral
neck.
• Make a trans-trochantric
osteotomy and a second
osteotomy at right angle to
the first, at superior edge
of lesser trochanter, to
leave the lesser trochanter
with distal fragment.

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

104. • Fix the osteotomy internally with large screws and
washer.
• Re-attach the greater trochanter to proximal and distal
fragment with screws.
• Post op after one yr
Postoperative: skin traction is given for 2-3 weeks
• active range of motion exercises of hip are begun at 10-14
days.

105. LEGG CALVE PERTHES DISEASE:
PATHOLOGY:
• Self limited disease of avascular necrosis of
ossification center of the capital epiphysis,
resulting in variable degree of deformity of femoral
head.
AIM:
• To prevent or minimize residual deformity of
femoral head by creating the biomechanical
environment which is not detrimental to normal
growth and remodeling of epiphysis.
• This is achieved by containing the femoral head
within the acetabulum.

106. VARUS DE-ROTATION OSTEOTOMY
AIM :
• By reducing the ante-version and neck shaft angle to
obtain maximum coverage of the femoral head.
• This osteotomy is done before 4 years of age, as after
this age, there are less chances of Acetabular
remodeling.
DISADVANTAGES:
1. Excessive varus angulation that may not correct with
growth
2. Further shortening of already shortened extremity
3. Possibility of a gluteus lurch produced by decreasing
the length of the lever arm of the gluteus musculature.

107. • The degree of de roration is estimated with the amount
of internal rotation but furthur adjustments can be made
during the surgery.
• If the internal rotation is severely limited even after 4
weeks of bed rest with traction
Varus osteotomy is done along with
extension by giving slight backward tilt to the proximal
segment.

108. TECHNIQUE:
• With patient supine make lateral
incision from greater trochanter
distally 8 to 12cm exposing lateral
aspect of femur.
• Mark the level of osteotomy at the
level of lesser trochanter or
slightly distal.

109. • Insert the guide pin
and do reaming of
the femoral head.
• Insert the barrel guide
into the back of the
implanted lag screw.
• Make the osteotomy cut
& tilt the head into varus .

110. • Using the side plate and screws firmly join the
proximal and distal fragments.
• Spica cast is worn for 8-12 weeks and internal
fixation can be removed after 1-2 years.

111. OTHER 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.
– Technique: Described in CDH.
4. VALGUS EXTENSION osteotomy: Indicated in malformed femoral
head in residual Perthe's disease with hinge abduction.
– Technique: Described in Osteoarthritis

112. SLIPPED CAPITAL FEMORAL EPIPHYSIS
• In this condition, the epiphysis is displaced inferiorly
causing adduction and external rotation deformity of
the limb.
AIM:
Osteotomy is performed here to reposition the
femoral head (epiphysis) concentrically within the
acetabulum.
INDICATIONS:
– Chronic slip with moderate to severe
displacement.
– Malunited slip

113. TWO BASIC TYPES:
• Closing wedge osteotomy of neck: Usually associated with
serious complications of AVN and chondrolysis, therefore
these osteotomies are not recommended. These are of four
types.
a. The technique of Fish
b. Technique of Dunn just distal to slip
c. Base of neck technique by Kramer et al d.
d. Technique of Abraham et al
• Compensatory osteotomies through the Trochantric region:
These osteotomies produce a deformity in the opposite
direction. It includes
a. Ball and socket osteotomy
b. Biplane intertrochanteric osteotomy
(Southwick)

114. 1. CUNEIFORM OSTEOTOMY
OF FEMORAL NECK (FISH):
• Fish recommended this in
moderate to severe slips of
more than 30°.
• Capsule is incised & femoral
neck is exposed.
• Locate the physis.
• Determine the size of wedge
to be removed by noting the
degree of slip.

115. • Adjacent to the
epiphyseal plate, a wedge
shaped piece of bone is
removed with its base
directed anteriorly and
superiorly with apex
psotero-inferiorly.
• Take care that osteotome
does not penetrate the
intact posterior periosteum,
damaging retinacular
vessels.

116. • Reduce the epiphysis
by flexion, abduction
and internal rotation of
limb, taking care to put
much tension on the
posterior periosteum,
capsule and vessels.
After reduction fix the epiphysis to neck with 2-3 pins six
inches long threaded on one half of their lengths with a
nut on the thread. Do not penetrate articular cartilage.

117. CUNIEFORM OSTEOTOMY OF FEMORAL NECK
(DUNN):
• Dunn described an osteotomy for severe
chronic slips in children with open physis.
• This procedure should not be done if the
physis is closed.
• Anterosuperior wedge of the most superior part
of the femoral neck is removed

118. TECHNIQUE :
• Through a lateral approach
• A. Greater trochanter is detached.
• B. Synovium is elevated from anterior and
postero-lateral surface of femoral neck with
periosteum elevator.

119. • C. Head is freed of all fibrocartilage and callus.
• D. Osteotomy line on upper end of femoral neck
is made for excision of trapezoid segment. (
anterosuperior wedge )

120. • E. Head of femur is replaced on femoral neck
and three threaded Steinmann pins are used for
fixation of shaft, head, and neck of femur.
• F. Two cancellous screws are used to fix greater
trochanter in normal position.

121. Osteotomies at base of neck – KRAMER,BARMADA
• Intracapsular base of neck osteotomy – for
chronic slips with > 20 ° of deformity
• Extracapsular base of neck osteotomy – for
moderate to severe chronic slips with > 30 ° of
head shaft angle

123. Intertrochanteric Osteotomy - SOUTHWICK
• BIPLANE osteotomy
• Anterolaterally based wedge
• At the level of lesser trochanter
• Indications :
- for chronic / healed slips with head shaft deformities
between 30 – 70 °
• Corrects extension / varus deformity with flexion /
extension of the distal fragment , and internal rotation as
needed

124. Southwick Intertrochanteric Osteotomy

125. OSTEOTOMY TO CORRECT UNSTABLE
INTERTROCHANTERIC FRACTURES
• Dimon and Hughston :
– Medial displacement osteotomy to stabilise unstable 4
part IT fracture
– In 4part # adductors tend to displace fracture into varus
secondary to lack of medial cortical opposition
– Chang et al - anatomical reduction allow greater load
shearing by bone than medial displacement osteotomy.
(CORR 1987 Dec;(225):141-6)

126. • Technique:
• If GT remains attached to femur ,a transverse osteotomy needs to
be made at a level 2cm below LT
• GT fragment is reflected superiorly
• Steinman pin inserted into the superior third of femoral head
• Key the calcar spike (proximal fragment )into the medially displaced
distal fragment
• Guide wire is placed into the lower half of femoral head
• The wire position will ensure a more valgus orientation of femoral
neck,once the screw and side plate have been applied
• Determine and insert the appropriate compression screw
• Abduct the thigh to bring the reduction into valgus
• Apply the side plate – 135deg, short barrel
• Release traction and apply the compression screw
• Reattach the GT fragment with wires

127. DIMON AND HUGHSTON INTERTROCHANTERIC
OSTEOTOMY

128. SARMIENTO OSTEOTOMY
• Involves creating an oblique osteotomy of the distal
fragment(valgus osteotomy) to obtain stability in unstable
IT #
• Changes # plane from verticle to near horizontal
• Creates contact b/w medial and posterior cortex of
proximal and distal fragments
• Goal – to obtain medial stability
• Adv – valgus realignment of proximal fragment makes up
for less of length at osteotomy site so that limb lengths
are equal

129. Technique:
• A 45° oblique osteotomy of distal fragment begins just
below flare of GT & crosses distally and medially to exit
about 1cm distal to the apex of #
• Guide wire and then implant are inserted at 90° to plane
of # of proximal fragment
• With more vertical alignment of # ,insert guide pin so that
it ends up more inferiorly in the femoral head ( other wise
,the osteotomy will be placed in varus)
• Insert 135 sliding screw in usual manner
• # is reduced and impacted
• Medial cortex opposition and hence stability are restored

130. OSTEOTOMY TO CORRECT UNSTABLE
INTERTROCHANTERIC FRACTURES
• Sarmiento Technique

133. Referrences
1. Tachdjian’s Paediatric Orthopaedics – 5th edition
2. Master techniques in Orthopaedic surgery – Paediatrics, -
Vernon.T.Tolo,David L Skaggs 1st edition
3. Campbell’s Operative Orthopaedics -12th edition
4. Wheeless’ text book of Orthopaedics-
www.wheelessonline.com.ortho – Clifford
R.Wheeless,III,M.D
5. Ramond g.Tronzo ,Surgery of hip joint 2012. – volume 1
6. Reinhold Ganz MD,Kevin Horowitz MD,Micheal Leunig MD- Algorithm
for femoral and periacetabular osteotomies in complex hip
deformities- CORR(2010) 468;3168-3180

134. 7. Intertrochanteric femoral osteotomies for developmental
and post traumatic conditions – Santore ,Richard
F;Kantor,Stephen R . JBJS;Nov 2004;86,11
8. Internet : WWW.ORTHOPAEDICSONE.COM – Pelvic
osteotomies;Sutherland osteotomy
9. Double Innominate osteotomy –DH Sutherland , JBJS
Am,1977