Pelvis osteotomies in ddh patients
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Pelvis osteotomies in ddh patients
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Pelvis osteotomies in ddh patients
- 1. Dr. Yousef T. Khoja Tutors Prof. Mamoun Kremli Dr. Kholoud Al-Zain
- 2. DDH Management Overview O 0 - 6 months O Pavlik Harness O 6 Months - 2 years, failed Pavlik O Closed Reduction & Hip Spica Cast 3 months O ± Tenotomies O 2 - 3 years, failed closed reduction O Open Reduction O 3+ years O Open Reduction O ± Femoral Osteotomy O ± Pelvic Osteotomy
- 3. Definition OJoint preservation operation designed at restoring the normal biomechanical environment to the hip joint
- 4. Hip Biomechanics O Hip designed to support BW permit mobility O Forces across hip joint O BW O Ground reaction forces O Abductor muscle forces O Forces acting around hip can be measured with - Mathematical model calculations - 2D static analysis
- 5. Hip Biomechanics O One legged stance 5/6 BW on femoral head O Ratio of lever arms to BW 3:1
- 7. Hip Biomechanics O Pathomechanical factors: O Increase body weight. O Increase body weight moment arm. O Decrease abductors force. O Decrease abductors moment arm.
- 9. Hip Biomechanics O 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 O In DDH, the ratio of lever arm of the body weight to that of the abductors may be 4:1. O The length of two lever arms can be surgically changed to make their ratio 1:1
- 10. Hip Biomechanics O Strategies to reduce JRF are achieved via: O Reducing Body Weight or its moment arm O Help Abductor Force or its moment arm
- 11. Aim of Osteotomies OOsteotomies improve hip function O Restore biomechanical advantage by Decreasing joint reactive forces O Increasing contact area / congruency O Improve coverage of head O Moving normal articular cartilage into weight bearing zone
- 12. Case # 1 O 31/2 years girl presented to your clinic O It was evident when she first began to walk that her gait was abnormal, O No prior treatment.
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- 17. Case # 2 O 28 y/o lady with severe left hip pain. O Pain for 6 years, no clicking in hip. O Unable to exercise due to pain. O On PE, O hip flexion at 90 degrees with IR of 10 degrees., Right hip IR is 25 degrees.
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- 24. Classification O Redirectional O Salter (Single innominate) O Steel (Triple innominate) O Ganz (Periacetabular) O Acetabuloplasties O Pemberton O Dega O Salvage O Shelf O Chiari
- 25. Salter Osteotomy O Single Innominate osteotomy O Described by Salter in 1961. O Age: 18 months - 6 years O Designed to cover anterolaterally deficiency O Up to 15 in acetabular index O 20 - 22 in center-edge angle O Hinges through the symphysis pubis
- 26. Salter Osteotomy O Prerequisites: O Sufficient articular cartilage O Mobile symphysis pubis O Congruous & concentrically reduced hip O Iliopsoas and adductor tenotomies often required O Range of motion of the hip must be good specially in abduction, int rotation & flexion O Not recommended with bilateral DDH
- 37. Salter Osteotomy O Postoperative: O A one-and-half hip spica is applied with the leg in about 20 flexion, 30 abduction, and neutral or slight internal rotation for 6 - 8. O The threaded pins can be removed in 6-8 weeks, depending on the radiographic union at the osteotomy site. O If an open reduction is done, hip spica cast is preferred for 10 -12 weeks.
- 39. Classification O Redirectional O Salter (Single innominate) O Steel (Triple innominate) O Ganz (Periacetabular) O Acetabuloplasties O Pemberton O Dega O Salvage O Chiari O Shelf
- 40. Steel Osteotomy O Triple Innominates osteotomy O Salter osteotomy + osteotomies of the ischium & pubis O Described by Steel in 1965. O Age: Skeletal mature (over the age of 6-8 yrs) O Recommended after closure of the ischial epiphysis O Rotates to cover any acetabular defect
- 41. Steel Osteotomy O Prerequisites: O Sufficient articular cartilage O Congruous & concentrically reduced hip O Functional range of motion of the hip O No upper age limit
- 42. Steel Osteotomy O Multiple incision technique O Posterior through gluteal O Allows osteotomy of ischium O Anterior freeing medial attachments O Allows Salter and superior ramus osteotomy O Rotate acetabulum as desired O Avoid externally rotating O Bone graft wedge, fix as per Salter type
- 48. Classification O Redirectional O Salter (Single innominate) O Steel (Triple innominate) O Ganz (Periacetabular) O Acetabuloplasties O Pemberton O Dega O Salvage O Chiari O Shelf
- 49. Ganz Osteotomy O Periacetabular osteotomy (PAO) O Extensive acetabular reorientation, including medial and lateral displacement. O Described by Ganz in 1988. O Age: Skeletal mature; adolescents & adults O Crosses the triradiate cartilage O Achieves correction of containment & congruency of the femoral head with little or no arthritis. O Easily combined with trochantericosteotomy
- 50. Ganz Osteotomy O Preserves blood supply to the acetabular fragment O The posterior column is split vertically O Immediate crutch weight bearing. O True pelvis unchanged O Can be combined with trochanteric osteotomy if needed O Technically extremely difficult
- 51. Ganz Osteotomy O Single surgical approach O Smith Peterson approach O lateral wall exposed O 4 cuts through the pubis, ilium, & ischium.
- 52. Ganz Osteotomy O 1st Osteotomy: Anterior Ischium
- 53. Ganz Osteotomy O 1st Osteotomy: Anterior Ischium
- 54. Ganz Osteotomy O 1st Osteotomy: Anterior Ischium
- 55. Ganz Osteotomy O 1st Osteotomy: Anterior Ischium
- 56. Ganz Osteotomy O 2nd Osteotomy: Pubis
- 57. Ganz Osteotomy O 2nd Osteotomy: Pubis
- 58. Ganz Osteotomy O 2nd Osteotomy: Pubis
- 59. Ganz Osteotomy O 3rd Osteotomy: supra-acetabular anterior limb O 1 cm anterior to the sciatic notch
- 60. Ganz Osteotomy O 4th Osteotomy: supra-acetabular posterior limb
- 61. Ganz Osteotomy O 4th Osteotomy: supra-acetabular posterior limb
- 62. Ganz Osteotomy O 4th Osteotomy: supra-acetabular posterior limb
- 63. Ganz Osteotomy O Connect the osteotomies O Mobilizing the Fragment by Schanz screw is placed superior to the acetabulum
- 79. Ganz Osteotomy CEA 28 degrees CEA 43 degrees
- 83. Classification O Redirectional O Salter (Single innominate) O Steel (Triple innominate) O Ganz (Periacetabular) O Acetabuloplasties O Pemberton O Dega O Salvage O Chiari O Shelf
- 84. Pemberton Osteotomy O Pericapsular incomlete osteotomy O Described by Pemberton in 1965. O Age: 18 months - 10 years O Hinges through triradiate cartilage O Designed to cover anterolaterally deficiency O More than 15 in acetabular index O Can be alter to cover posterior O Reduces acetabular volume
- 85. Pemberton Osteotomy O Prerequisites: O Open triradiate cartilage O Small femoral head O Sufficient articular cartilage O Congruous & concentrically reduced hip O Iliopsoas and adductor tenotomies often required O Functional Range of motion
- 86. Pemberton Osteotomy O Anterior Approach - Exposure as for Salter O Expose the inner and outer tables of the ilium O The outer ilium is osteotomized beginning 1 cm above AIIS O The inner ilium is osteotomized separately to match the outer cut O Lever through cut until coverage acceptable O Levers on tri-radiate cartilage O Hold correction with bone graft wedge O No internal fixation is required.
- 91. Classification O Redirectional O Salter (Single innominate) O Steel (Triple innominate) O Ganz (Periacetabular) O Acetabuloplasties O Pemberton O Dega O Salvage O Chiari O Shelf
- 92. Dega Osteotomy O Similar to Pemberton O Cutting only the lateral aspect of the ilium O Provides posterolateral coverage O More inner table –more anterior coverage O Less inner table –more lateral coverage
- 98. Classification O Redirectional O Salter (Single innominate) O Steel (Triple innominate) O Ganz (Periacetabular) O Acetabuloplasties O Pemberton O Dega O Salvage O Chiari O Shelf
- 99. Chiari Osteotomy O Primary indication is a painful, subluxated incongruent hip & no other osteotomy possible O Age: older than 8 years of age O Covers well laterally O The amount of coverage depends on the width of the ilium. O Anterior and posterior shelf augmentation may be need
- 100. Chiari Osteotomy O Prerequisites: O Incongruent hip O Satisfactory range of motion, O Maintenance of the cartilage space O Minimal osteoarthritis. O No other osteotomy possible
- 101. Chiari Osteotomy O Anterolateral approach O Exposed the ilium to the sciatic notch. O Identify superior extent of capsule O The ilium is osteotomized between the capsule and the reflected head of the rectus & curved the capsular insertion O Displace distal fragment medially 50-100% O by forced abduction with rotation through the pubic symphysis O Ensure complete head coverage O Fixed with threaded pins, O Hip spica cast for approximately 6 weeks.
- 102. Chiari Osteotomy
- 103. Chiari Osteotomy
- 104. Chiari Osteotomy
- 105. Chiari Osteotomy
- 106. Chiari Osteotomy
- 107. Classification O Redirectional O Salter (Single innominate) O Steel (Triple innominate) O Ganz (Periacetabular) O Acetabuloplasties O Pemberton O Dega O Salvage O Chiari O Shelf
- 108. Shelf Osteotomy O Primary indication is a painful, subluxated incongruent but don’t necessitate chairi or augmentation is needed O Described by Staheli and Chew O Age: older than 8 years of age O Augments supero-lateral deficency O Prevent the subluxation of the femoral head O Expand the load-bearing area of the hip joint
- 109. Shelf Osteotomy O Prerequisites: O Intact labrum O Incongruent hip O Satisfactory range of motion, O Maintenance of the cartilage space with minimal osteoarthritis.
- 110. Shelf Osteotomy O Anterior approach, outer wall exposure only O Identify superior acetabular edge O Create slot 1cm deep along edge O Remove 1 cm cortical strips from outer table O Insert into slot, cutting at desired lateral overhang O Hold in place with reflected fascia and adductors O Use remaining to fill in above slot edge
- 111. Shelf Osteotomy
- 112. Shelf Osteotomy
- 113. Shelf Osteotomy
- 114. Shelf Osteotomy
- 115.
- 116. Resources O Pelvic Osteotomies for the Treatment of Hip Dysplasia in Children and Young Adults; J Am Acad Orthop Surg 1999;7:325-337 O Master Techniques in Orthopaedic Surgery: Pediatrics, 1st Edition O Lovell & Winter's Pediatric Orthopaedics, 6th Edition O AAOS Comprehensive Orthopaedic Review O Atlas of Pediatric Orthopaedic Surgery, 3rd edition O Gandhi Medical College: Seminar on Osteotomies Around Hip O Dr. Dale Williams: Pelvic Osteotomies presentation O Dr. Trevor Stone: Hip Biomechanics and Osteotomies presentation O Wheeless' Textbook of Orthopaedics O International Hip Dysplasia Institute O WebMD O Hospital for Special Surgery O orthobullets.com O kneeandhipsurgeon.com
Editor's Notes
- 1 year after the procedure
- age of 6 years, 21/2 years after the open reduction.
- CEA= 28 degrees
- (a) The center-edge angle is reliable only in patients older than 5 years. (b) A center-edge angle <20° is considered abnormal.
- Not recommended with bilateral DDH because it may uncover opposite hip.
- Gigli saw is passed through the notch and directed anteriorly. The osteotomy should exit just above the anterior inferior iliac spine
- Care should be taken to prevent displacing the proximal fragment, which would lead to opening of the osteotomy posteriorly at the sciatic notch and lengthening of the affected limb
- fixed by 2 threaded pins or screws directed posteromedially. Hardware fixation not only prevents the loss of correction but also helps prevent graft collapse.
- 16-year-old patient with residual dysplasia after treatment for developmental dislocation of the hip (DDH) and pain
- - preservation of the shape of the pelvis, which permits normal vaginal delivery
- The first cut is made distal to the acetabulum and travels posteriorly toward the ischial spine; this cut requires the use of a curved Ganz osteotome. True anteroposterior (AP) and false-profile views using fluoroscopy are essential while the cuts are advanced.
- The first cut is made distal to the acetabulum and travels posteriorly toward the ischial spine; this cut requires the use of a curved Ganz osteotome. True anteroposterior (AP) and false-profile views using fluoroscopy are essential while the cuts are advanced.
- The first cut is made distal to the acetabulum and travels posteriorly toward the ischial spine; this cut requires the use of a curved Ganz osteotome. True anteroposterior (AP) and false-profile views using fluoroscopy are essential while the cuts are advanced.
- The first cut is made distal to the acetabulum and travels posteriorly toward the ischial spine; this cut requires the use of a curved Ganz osteotome. True anteroposterior (AP) and false-profile views using fluoroscopy are essential while the cuts are advanced.
- The second cut is made in the superior ramus just medial to the iliopectineal eminence. It should be more oblique to assist in translating the joint medially.
- The second cut is made in the superior ramus just medial to the iliopectineal eminence. It should be more oblique to assist in translating the joint medially.
- The second cut is made in the superior ramus just medial to the iliopectineal eminence. It should be more oblique to assist in translating the joint medially.
- The third cut (the supra-acetabular cut) is begun just distal to the anterior superior iliac spine. Only a small lateral window, made by stripping the abductor musculature, is necessary to execute this cut. This abductor-sparing approach helps in 3 ways: it keeps the blood supply of the acetabulum intact, it minimizes the formation of HO, and it assists in maintaining strong abductor function and avoiding a Trendelenburg lurch.
- - is directed toward to the ischial spine (do not enter into the joint or sciatic notch); - The fourth and final cut is made down the posterior column of the pelvis. This is done under fluoroscopic guidance with a false-profile view, allowing the surgeon to make the cut between the posterior margin of the acetabulum and the posterior aspect of the posterior column.
- - is directed toward to the ischial spine (do not enter into the joint or sciatic notch); - The fourth and final cut is made down the posterior column of the pelvis. This is done under fluoroscopic guidance with a false-profile view, allowing the surgeon to make the cut between the posterior margin of the acetabulum and the posterior aspect of the posterior column.
- - is directed toward to the ischial spine (do not enter into the joint or sciatic notch); - The fourth and final cut is made down the posterior column of the pelvis. This is done under fluoroscopic guidance with a false-profile view, allowing the surgeon to make the cut between the posterior margin of the acetabulum and the posterior aspect of the posterior column.
- Once the osteotomies are complete, a Schanz screw is placed superior to the acetabulum and used to position the acetabular fragment; it is then fixed with provisional pins. Final optimal lateral and anterior coverage should be verified under imaging guidance while the normal version of the acetabulum is maintained. Care should be exercised to avoid excessive anterior coverage, which can produce impingement leading to labral and cartilage damage. After the positioning of the acetabular fragment, the hip should be flexed to 90° to ensure that impingement has not been created.
- Once the osteotomies are complete, a Schanz screw is placed superior to the acetabulum and used to position the acetabular fragment; it is then fixed with provisional pins. Final optimal lateral and anterior coverage should be verified under imaging guidance while the normal version of the acetabulum is maintained. Care should be exercised to avoid excessive anterior coverage, which can produce impingement leading to labral and cartilage damage. After the positioning of the acetabular fragment, the hip should be flexed to 90° to ensure that impingement has not been created.
- Once the osteotomies are complete, a Schanz screw is placed superior to the acetabulum and used to position the acetabular fragment; it is then fixed with provisional pins. Final optimal lateral and anterior coverage should be verified under imaging guidance while the normal version of the acetabulum is maintained. Care should be exercised to avoid excessive anterior coverage, which can produce impingement leading to labral and cartilage damage. After the positioning of the acetabular fragment, the hip should be flexed to 90° to ensure that impingement has not been created.
- Once the osteotomies are complete, a Schanz screw is placed superior to the acetabulum and used to position the acetabular fragment; it is then fixed with provisional pins. Final optimal lateral and anterior coverage should be verified under imaging guidance while the normal version of the acetabulum is maintained. Care should be exercised to avoid excessive anterior coverage, which can produce impingement leading to labral and cartilage damage. After the positioning of the acetabular fragment, the hip should be flexed to 90° to ensure that impingement has not been created.
- Once the osteotomies are complete, a Schanz screw is placed superior to the acetabulum and used to position the acetabular fragment; it is then fixed with provisional pins. Final optimal lateral and anterior coverage should be verified under imaging guidance while the normal version of the acetabulum is maintained. Care should be exercised to avoid excessive anterior coverage, which can produce impingement leading to labral and cartilage damage. After the positioning of the acetabular fragment, the hip should be flexed to 90° to ensure that impingement has not been created.
- Once the osteotomies are complete, a Schanz screw is placed superior to the acetabulum and used to position the acetabular fragment; it is then fixed with provisional pins. Final optimal lateral and anterior coverage should be verified under imaging guidance while the normal version of the acetabulum is maintained. Care should be exercised to avoid excessive anterior coverage, which can produce impingement leading to labral and cartilage damage. After the positioning of the acetabular fragment, the hip should be flexed to 90° to ensure that impingement has not been created.
- Once the osteotomies are complete, a Schanz screw is placed superior to the acetabulum and used to position the acetabular fragment; it is then fixed with provisional pins. Final optimal lateral and anterior coverage should be verified under imaging guidance while the normal version of the acetabulum is maintained. Care should be exercised to avoid excessive anterior coverage, which can produce impingement leading to labral and cartilage damage. After the positioning of the acetabular fragment, the hip should be flexed to 90° to ensure that impingement has not been created.
- Once the osteotomies are complete, a Schanz screw is placed superior to the acetabulum and used to position the acetabular fragment; it is then fixed with provisional pins. Final optimal lateral and anterior coverage should be verified under imaging guidance while the normal version of the acetabulum is maintained. Care should be exercised to avoid excessive anterior coverage, which can produce impingement leading to labral and cartilage damage. After the positioning of the acetabular fragment, the hip should be flexed to 90° to ensure that impingement has not been created.
- Fixation from anterior ilium to posterior column with a 3.5 mm cortical bone screw
- Fixation from anterior ilium to posterior column with a 3.5 mm cortical bone screw
- 2 more 3.5 cortical bone screws from iliac crest into fragment!! AIIS is removed and can be used as bone graft into the anterior gap of the transverse osteotomy
- 2 more 3.5 cortical bone screws from iliac crest into fragment!! AIIS is removed and can be used as bone graft into the anterior gap of the transverse osteotomy
- 2 more 3.5 cortical bone screws from iliac crest into fragment!! AIIS is removed and can be used as bone graft into the anterior gap of the transverse osteotomy
- 17 year old boy with painful left hip. Note large dysplastic acetabulum and femoral head subluxation on the patient’s left side. The head of the femur is moving in a false socket high on the side of the pelvis.
- The arthrogram below shows that the hip can be put back into the true socket.
- The osteotomy extends posteriorly 0.25 inch above and parallel to the joint capsule and is carried to the ilioischial limb of the triradiate cartilage Care must be taken to remain halfway between the anterior edge of the sciatic notch and the posterior rim of the acetabulum. The osteotomy is opened enough to create an acetabular angle of approximately 0 degrees. A groove is created to hold the graft in position, and a triangular wedge of bone from the anterior ilium is placed and impacted.
- X-ray showing residual acetabular dysplasia on right side.
- Immediate post-op image of pelvis and hip after Dega pelvic osteotomy.
- Final appearance of pelvis and hip 18 months after Dega pelvic osteotomy.
- act to increase the weight-bearing surface and rely on capsular metaplasia to provide an articulating surface
- The procedure brings the hip joint medially, in addition to expanding the contact area of the femoral head
- act to increase the weight-bearing surface and rely on capsular metaplasia to provide an articulating surface
- Provides an extra articular buttress
- - A 1-cm-deep slot is made and continued as far anteriorly and posteriorly as is needed for coverage without blocking flexion anteriorly. - secured by bringing the reflected head of the rectus forward over the graft and suturing it back to its original position. The remaining graft is placed above the initial layer to act as an additional buttress.
- A 14-year-old girl presented with bilateral hip dysplasia secondary to developmental dysplasia of the hip (DDH). Bilateral shelf procedures were augmented with abundant iliac crest bone graft (Fig. 14-5).
- After 2 years, the graft appeared to be consolidated, with excellent augmentation of the acetabulum.